Teaser Excerpt from The Paleo Approach: Histamine Intolerance

June 3, 2013 in Categories: , , , , by

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The Paleo Approach by Sarah BallantyneThere are many topics that I am researching and writing about for the book that I’ve been meaning to write about for the blog for ages (the book just gives me a firm deadline). I have decided take some of these topics (especially the more blog-sized ones) and publish them as teaser excerpts for the book (also because I think this information should be here too).

This excerpt is from Chapter 9, which is the troubleshooting Chapter.  Chapter 9 discusses confounding factors, such as: additional food sensitivities and allergies, micronutrient deficiencies, gut-brain axis problems, severe cases of SIBO, digestive difficulties and severely leaky guts, persistent infections and parasites, and the need for organ function support.  Many supplements are also discussed throughout this chapter, both supplements that might be helpful and supplements that are commonly taken that may be hindering healing.  Most of Chapter 9 is designed to give you extra information to help you start a dialogue with a healthcare professional and this information should not be used for the purpose of self-diagnosis.

This section on histamine intolerance comes after a more general discussion of food allergies, intolerances and sensitivities.

So, forgive the references to other chapters and page numbers with no number. While you’ll have to wait until the book is out in to read those sections, in the meantime, please enjoy this part of Chapter 9: Troubleshooting

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Histamine intolerance is a condition caused by a disequilibrium of accumulated histamine and the capacity of histamine degradation, i.e., when there is more histamine in your body (generally, consumed in the foods you eat and/or produced within your body) than your body can effectively handle.  Histamine (which you will recognize as the key chemical produced by your body during an allergic reaction, see page ##) is a type of molecule called a biogenic amine, which is created by removing the carboxyl group off of an amino acid (see page ##).  In the case of histamine, the amino acid that is “decarboxylated” is histidine.  Histamine is a normal part of the diet (at least in small amounts) and also a normal product of the bacteria in our guts.  In healthy people, histamine and other biogenic amines are rapidly detoxified by enzymes in the gut.  In the case of histamine intolerance however, either production of histamine is unusually high or activity of these detoxification enzymes is unusually low (or both).  

Histamine can be inactivated by two different enzymes.  Diamine oxidase (DAO) is secreted by enterocytes and works outside of the cells and even in the lumen of the gut to convert histamine into imidazole acetaldehyde, thereby inactivating the histamine.  DAO forms the primary barrier for intestinal absorption of histamine.  A second enzyme, found within enterocytes and called histamine N-methyltransferase (HMT), converts histamine into N4-methylhistamine, also thereby inactivating the histamine.  While most studies implicate insufficient levels of DAO as the problem in histamine intolerance, insufficient HMT may also be a contributor.  Histamine intolerance may also be related to certain genetic mutations in the gene for DAO that impair the efficiency of DAO activity (these mutations appear to be much more frequent in Caucasians compared to other ethnicities, although more studies are required).

If the gut barrier is damaged, DAO is not secreted in adequate quantities by the gut enterocytes.  Furthermore, a leaky gut can allow histamine to enter the body without passing through enterocytes where it would normally be degraded by HMT.  Also, HMT inactivates histamine via a methylation process, so micronutrient deficiencies may contribute to reduced activity of HMT (see page ##).  For histamine to cause adverse reactions and symptoms, it has to be absorbed and enter the bloodstream without being inactivated by DAO or HMT.  This seems likely in those with severely leaky guts.

Furthermore, histamine production may be substantially higher in those with gut dysbiosis, especially SIBO.  Histamine production in food is generally the result of food handling, processing or fermentation.  Certain foods are particularly susceptible to developing significant amounts of histamine through processing/packaging, including: fish, processed and fermented meats, cheeses, fermented vegetables and soy products, and alcoholic beverages.  A wide variety of bacteria are capable of metabolizing histidine into histamine.  These are called decarboxylasepositive microorganisms and they can typically produce other biogenic amines in addition to histamine.  As a general rule, these bacteria are associated with food spoiling, although their activity can generate problematic amounts of histamine long before a food is considered rotten.  Histamine-producing bacteria include many species from the following genera:  Lactobacillus, Clostridium, Morganella, Klebsiella, Hafiia, Proteus, Enterobacter, Vibro, Acinetobacter, Pseudomonas, Aeromonas, Plesiomonas Staphylococcus, Pediococcus, Streptococcus and Micrococcus.  Even Escherichia coli are histamine-producing bacteria.  You may recognize many of these as normal residents of the gut (likely why we need a DAO barrier in the first place) and even more importantly, several of these are likely to be present in excessive numbers during SIBO (see page ##).  This means that not only can these types of bacteria cause increased levels of histamine in your food before you eat it, but they may also be creating large amounts of histamine in your gut.

How do these histamine-producing bacteria get into certain foods?  Generally, these are bacteria ubiquitously present in the environment.  For example, the vast majority of these bacteria are native to aquatic environments, so they are already present on and even in fish before the fish are ever taken out of the water.  They tend to be inactive below 15°C so histamine production in fish is typically the result of fish not being handled properly (i.e., not chilled quickly enough after being removed from the water and/or not being kept at sufficiently low temperatures through handling/processing/packaging) or being refrigerated for a long time (most fish have negligible histamine levels if you measure fresh out of the ocean/lake).  Histamine production in foods is considered a contaminant, or indicator of food spoilage.  It is actually a source of food poisoning, especially in fish.  Although, in some cases histamine-producing bacteria are deliberately added to foods, such as in the context of cheese and fermented sausages, soy products and vegetables (although clearly the goal of adding these bacteria is not to produce histamine, but rather to jump start the fermentation process). 

There are some other factors that contribute to histamine intolerance.  If basal cells and mast cells are activated as part of you autoimmune disease or as a result of an undiagnosed allergy (food allergy or environmental allergy), this may increase your sensitivity to histamine from foods, simply because your basal level of histamine production is higher.  A variety of drugs inhibit the activity of DAO, including some commonly-prescribed muscle relaxants, narcotics, analgesics, local anesthetics, antihypertensive drugs, diuretics, antibiotics, H2 blockers (see page ##), and antidepressants, among others.  Alcohol also inhibits the activity of DAO plus both wine and beer contain significant levels of histamine (red wine being especially high).

Symptoms of histamine intolerance resemble allergy symptoms, and may include: diarrhea, headache, sinus symptoms, asthma, low blood pressure, rapid, slow or irregular heart rate, hives, rashes, flushing, and any other symptom typically associated with allergies (see page ##).  Typically, symptoms are felt relatively quickly after consumption of high-histamine foods. Keeping a food and symptom journal is the most common way in which histamine intolerance is diagnosed; however, histamine and DAO can both be measured using blood tests which may help confirm diagnosis (there is some controversy over whether serum DAO is truly indicative of gut DAO).  It is estimated that 1% of the general population has histamine intolerance, most of whom are middle-aged.  However, many researchers believe that this is a gross underestimation since recognition of histamine intolerance as a pathology is very recent.

The typical recommendation for those with histamine intolerance is to follow a histamine-free diet.  This can be challenging since the histamine content of foods can be highly variable (since it is so dependent on handling and processing but also the specific bacteria strains which might be used in fermentation).  Furthermore, histamine content is not typically labeled by food manufacturers, and only measured to ensure food safety (since high levels of histamine cause food poisoning).  Antihistamines are only recommended when high amounts of histamine are accidentally consumed, and not for long-term therapy.  DAO supplementation is available (typically with encapsulated pig kidney enzyme); however, controlled clinical trials demonstrating the efficacy of DAO supplementation have not been performed. 

Many of the foods that frequently contain high levels of histamine are already omitted on The Paleo Approach.  This includes:  yogurt, sour cream, cheeses (gouda, camembert, cheddar, emmental, Swiss, harzer, talsiter, and parmesan), cured meats (fermented sausage, dry cured sausage, salami, fermented ham) which are only omitted if they contain nightshade- and/or seed-based spices, alcoholic beverages (white wine, red wine, champagne, sherry and beer), tomatoes, ketchup, eggplant, coffee, chocolate, cocoa and soy products, especially fermented soy products.  Foods that are likely to contain significant levels of histamine but are normally included on The Paleo Approach:

  • Fermented cured meats (normally included if only “safe” spices are used, see page ##)
  • Fermented sausages
  • Dry cured sausages
  • Fermented ham
  • Sauerkraut (and potentially other lacto-fermented fruits and vegetables)
  • Fish
    • Mackerel
    • Herring
    • Sardines (amount varies, some contain no histamine)
    • Tuna (amount varies, some contain no histamine)
    • Anchovy
    • Scad
    • Dried milkfish
    • Bonito
    • Pilchards
    • Marlin
    • Saury
    • Butterfly King Fish
    • Smooth-tailed Trevally
    • Other fish if stored for excessive periods of time or improperly handled
  • Fish sauce
  • Fish paste (e.g. anchovy paste)
  • Shrimp paste
  • Pork
  • Spinach
  • Green Tea
  • Orange
  • Banana
  • Tangerine
  • Grape
  • Strawberry
  • Pineapple
  • White wine (even if alcohol is cooked off, see page ##)
  • Red wine (even if alcohol is cooked off, see page ##)
  • Champagne (even if alcohol is cooked off, see page ##)
  • Sherry (even if alcohol is cooked off, see page ##)

The histamine content of each food varies (often dramatically), depending on how the foods were handled and/or processed before histamine levels were measured.  Plus, different foods are more or less susceptible to histamine formation.  Of the above foods, the average histamine content ranges from 2mg/kg to 4000mg/kg, so some foods might be tolerated (lower histamine content foods from this list are pineapple, strawberry, grape, tangerines and banana) whereas others might not (the highest concentration histamine foods from this list tend to be sausage, herring, mackerel, pork and spinach, but vary with handling procedures). 

A variety of foods have also been implicated to have histamine-releasing capacities, meaning that while they do not contain histamine, once they are ingested they can stimulate the release of histamine from mast cells.  Several of these foods are already omitted on The Paleo Approach, including: egg white, chocolate, cocoa, tomatoes, nuts, a variety of food additives, and some spices (not defined, but likely nightshades given the high amount of histamine in sausages, salami, tomatoes and eggplant).  However, some foods that are normally included on The Paleo Approach may also have histamine-releasing capacities, including:

  • Citrus fruits
  • Papaya
  • Strawberries
  • Pineapple
  • Spinach
  • Fish
  • Crustaceans
  • Pork
  • Licorice Root

Because the exact contribution that gut bacteria (especially in the context of bacterial overgrowth) make to the production of histamines in those with histamine intolerance is unknown (and likely highly variable), it is also unknown to what degree dietary intake of foods rich in the amino acid histidine should be avoided.  If you have been diagnosed with histamine intolerance and have had some (but incomplete) relief of your symptoms from avoidance of histamine-rich foods, eating smaller portions of meat, fish, and shellfish (all the highest dietary sources of histidine) may be worth discussing with a healthcare professional.  Certainly, following the recommendations already detailed (at great length!) in this book to restore both normal gut flora and the integrity of the gut barrier are important.  Because histamine intolerance reflects both a damaged and leaky gut and gut dysbiosis (except perhaps in the context of gene mutations), it is a sensitivity that is likely to diminish and eventually disappear completely while following The Paleo Approach

Interested in learning even more about The Paleo Approach? This video from my YouTube Channel is just a quick tour (the book is so big that giving you a broad overview takes 13 minutes!) but you get to see just how comprehensive and detailed this book is.

Bodmer, S., et al., Biogenic amines in foods: histamine and food processing, Inflamm Res. 1999 Jun;48(6):296-300

Chung, B.Y., et al., Treatment of Atopic Dermatitis with a Low-histamine Diet, Ann Dermatol. 2011 Sep;23 Suppl 1:S91-5

Ferreira, I.M. & Pinho, O., Biogenic amines in Portuguese traditional foods and wines, J Food Prot. 2006 Sep;69(9):2293-303

Kung, H.F., et al., Biogenic amine content, histamine-forming bacteria, and adulteration of pork in tuna sausage products, J Food Prot. 2012 Oct;75(10):1814-22

Maintz, L & Novak, N., Histamine and histamine intolerance, Am J Clin Nutr. 2007 May;85(5):1185-96

Masson, F., et al., Histamine and tyramine production by bacteria from meat products, Int J Food Microbiol. 1996 Sep;32(1-2):199-207

Papavergou, E.J., et al., Levels of biogenic amines in retail market fermented meat products, Food Chem. 2012 Dec 15;135(4):2750-5

Shalaby, A.R., Significance of biogenic amines to food safety and human health, Food Research International 1996;29(7):675-90

Visciano, P., et al., Biogenic amines in raw and processed seafood, Front Microbiol. 2012;3:188

Wantke, F., et al., Histamine-free diet: treatment of choice for histamine-induced food intolerance and supporting treatment for chronic headaches, Clin Exp Allergy. 1993 Dec;23(12):982-5

Comments

Great article – thank you!! For some reason- I thought low blood pressure was related to histamine intolerance. Did you come across this in any of your research?

Glad to catch your typo! :) I have been learning about histamine intolerance over these past few months and after going on a low histamine diet for about 6 weeks- my chronically low blood pressure has gone up to a normal range. I think histamine intolerance has been the “missing piece” in my gut- healing diet for the past two years. I kept eating lots of fermented foods, canned sardines, spinach and sausage and couldn’t figure out why I felt so blah still. Once I elimated the high histamine foods- my thinking became less foggy/ my eyes were not as blood shocked and my headaches went away. I hope my GI issues will continue to get better as I avoid them. Question- do you think taking a probiotic can help or hinder dealing with histamine intolerance issues?

Well, the typical lactobacillus/bifidobacterium probiotics might actually makes things worse since they can contribute to histamine production. But, SBOs like Prescript-Assist might be very helpful.

Thank you for this excerpt! I’ve been struggling with a strong histamine intolerance for a year now, though I didn’t know it until about 8 weeks ago, thanks to you cluing me into it.

Question–I love avocados, but if I eat too much, I experience histamine reactions, especially dizziness when I stand up. Can I still eat avocados in small quantities if it doesn’t cause the dizziness? (My common histamine reactions are dizziness and feeling my throat close up a bit. Lately the throat reaction is completely gone. I just know if I’ve eaten too many histamines by the dizziness.)

Also, I read that you shouldn’t eat dark chicken or turkey meat like chicken thighs because that part has more histamines than the white meat. True or not? I love chicken thighs but have been avoiding them just in case.

Thank you, thank you for all you do!

I could not find avocados listed in a single scientific journal article evaluating this histamine content of foods. But, if it causes a reaction, then I would avoid it, at least for now. The foods lists in this post represent every single food I could find listed in the scientific literature (no mention of turkey or chicken); but as I mention, there have not been comprehensive measurements of foods.

Thanks. I’ll try to give up avocados for another month or two and see how it goes. I’ll also try the turkey and chicken. One last question–what about pastured bacon that is only processed with salt? Should I avoid that too?

It hasn’t been measured. Fermented foods are usually not great, fish is usually not great, but histamine would be in the protein/water-soluble fraction and not the fat-soluble fraction. So, I’m not sure.

Thank you for explaining all of this! One question: Does the fact that I have chronic allergies (hayfever type) mean (or make it more likely) that I have histamine intolerance? I have all of the symptoms that you mentioned (since they are allergy symptoms) but I’m not sure if they are linked to certain foods.

No, not necessarily. Just because you have histamine overproduction in other parts of your body doesn’t mean that you have overproduction or a lack of DAO in your gut. Although a nutrient-dense paleo diet is still a good idea to deal with the allergies.

Every time I embark on a research crusade to figure out the roots of my son’s eczema, I wind up on this site. It has been less than 4 days since my stack of Joneja books arrived and here I am again! This is the best synopsis of histamine intolerance I have read so far. I, for one, I more excited about the upcoming book than I can express. I’ve been spreading the word and look forward to the release. Thank you!!

Did you find that chicken or beef liver are high in histamines too? I sometimes feel like these can cause a reaction such as redness in my hands and stiffer joints the following morning.

Man, low histamine diet + paleo = nothing to eat! I was wondering if you had done any research on MTHFR and histamine? I have terrible eczema and paleo has not done much to fix it, my ND wants me to put me on oral hydrocortisone which I am apprehensive about because it doesn’t really seem to fix anything root problem. I have noticed some issues with high histamine foods (namely, I remember nice soy sauce that my mom would get from japan would make my lips itchy and swell when eating sashimi. Same with eggplant..) But since skin is always crappy and tends to fluctuate in its flares its pretty hard to correlate anything with diet. Anyway! I was hoping to get your thoughts on these two studies:

DNA methylation of the filaggrin gene adds to the risk of eczema associated with loss-of-function variants
http://www.ncbi.nlm.nih.gov/pubmed/23003573

The association between atopy and factors influencing folate metabolism: is low folate status causally related to the development of atopy?
http://ije.oxfordjournals.org/content/35/4/954.full.pdf+html

I cling onto anything that might indicate that eczema is a lifelong problem I will have to deal with! Love your blog and the work that you do, looking forward to your book

You should not have to deal with eczema for your whole life. There is no general link between MTHFR variants and histamine intolerance (and having issues with soy and nightshades is more likely the fact that these are really bad foods for people with skin conditions rather than histamine intolerance), although there are certainly links between MTHFR variants and a variety of health conditions. I would suggest the autoimmune protocol, a focus on fish, organ meat, lots of vegetables, glycine-rich foods (and/or a Great Lakes collagen supplement) and probiotic foods (and/or Prescript-Assist)–hese things will help heal the gut and support methylation. Also focus on stress reduction, tons of sleep, and sun exposure. In addition, I would suggest exploring probiotic soaps and natural moisturizers (Check out my a-store because there are links to all of these in there–I am currently using Chrysal face and hand soap and love it although it’s only been a week, and I would suggest an animal-fat based moisturizer such as Green Pasture beauty balm and Vintage Traditions body balm… you may also want to buy some tamanu oil to mix in with those which can be very healing).

Thank you for the quick response and recommendations. The probiotic soaps sound really interesting, I will have to look into that. I am a nurse at a hospital and I have kind of dreamed of these kinds of products in the hospital setting, though I doubt the medical establishment would risk this avenue for the time being.

Is there a reason why you suggest the Great Lakes collagen supplement (over the gelatin)? I do quite a bit of bone broths but with the weather heating up I am thinking my soup intake might decline a bit and some supplementation might be helpful.

There are many establishments that are switching to Chrisal probiotic cleaners, and I would urge you to bring Chrisal to the attention of your hospital admin. It actually disinfects better than bleach without being hazardous to your hospital custodians’ health and is typically more economical (that last one might get their attention).

I think broth is better than collagen since it also has the mineral content. But, I myself take collagen when it’s been a while since I’ve made broth. It’s hydrolyzed so it’s more easily absorbed than gelatin and doesn’t thicken the way gelatin does so you can dissolve it even in a cold glass of water.

PaleoMom, I just read the entry from June and your reply to her. I have been using the Great Lakes Green gelatin. Is this what you are referring to as using? I have been having eczema and am trying to eliminate high-histamine foods. We used to make broth but don’t because of some of the issues relating to histamine. Do you feel the hydrolyzed Great Lakes green is ok histamine-wise, based on your experience and feedback from others? What are other benefits of continuing to use this in one’s diet, weighing the positive against potential histamine reaction?

Actually I don’t think the part about no connection between MTHFR and histamine is correct. MTHFR mutations affect methylation, and histamine degradation is a methylation processes. See this link: http://www.dramyyasko.com/resources/autism-pathways-to-recovery/chapter-2/ If methylation is low, histamine tends to be high. And a lot of the foods recommended to heal the gut are actually high histamine, which can be very complicating. I was just diagnosed with a REALLY BAD case of SIBO and am also homozygous for one of the MTHFR mutations. I seem to trade one set of symptoms for the other, and unfortunately BOTH are including dangerous weight loss (I’m 5′ 4 1/2″ and dropped to 93.2 lb this morning). I don’t know WHAT to do…what to EAT.

Is bone broth a no no when dealing with a histamine issue? I’ve not eaten it for several months because I thought the slow cooking would increase the histamine content. True?

I know that it’s listed on dozens of websites as being high histamine, but I could not find a single scientific article to support that. The bacteria that are responsible for creating histamine shouldn’t survive the cooking temperature (otherwise broth would go bad while you were cooking it). That being said, comprehensive measurements of histamines in food have not been made.

I never thought about bone broth and histamine — until yesterday when I started a big kettle of bone broth and within minutes was so dizzy, congested, and nauseated that I spent several hours in bed. I am allergic to July anyway, and a dose of Zyrtec and Sudafed eventually brought the congestion down, but am I nuts to think that the fumes from bone broth would do that? I’m much more allergic and generally reactive this year after a very bad Crohn’s flare last October that I’m still healing from, but this was still a surprise!

What is it about bone broth that makes it high histamine? Is there a histamine-containing foods list that you recommend — bone broth doesn’t appear on any that I’ve seen, but I have no question that it’s high histamine based on my experience.

Hi Sarah,

I have a dilemma with Histamine. The current dilemma as near as I can tell seems mainly to do with a reaction to histamine (a histamine intolerance) and it has come to affect both myself and my 5 year old daughter. We both have hyperpermeable intestinal membranes with 25 +/- food allergies/sensitivities each and autoimmune reactions as a result. She has had temporal seizures and developmental delays, especially with language, and depending on what she eats on any given day she can range in behavior and cognitive function from near normal to ADD, ADHD to borderline PDD. She used to be more solidly PDD, but has made great strides fortunately and is much more healthy now.

Basically we have both been helped by a Paleo/SCD/GAPS diet for about four years and for the last year have begun to augment our diet with fermented cabbage, pickles, melon and other creative fermentations. Like the diet, these fermented foods also vastly improved our well-being. When I ate them I was much more mentally sharp, had more facile access to long term memory and was amazingly more fluid in conversation than I had ever been in my life, really dramatically so. I’m guessing an important mechanism was not only the probiotics but also the effect of histamine on neurotransmitters, I’m not sure but whatever it was it was very powerful. My daughter’s behavior, social skills, attention and language complexity dramatically improved too. It was really fascinating and we were incredibly hopeful for the future.

However nine months ago I started to notice urticaria and became very itchy, and then after a few months I began to have strong headaches, intense neck and upper back stiffness, swollen lymph nodes in the back and neck and intense, constant, dull pain in my sternum — all the while still experiencing the great neurological benefits that so changed my work and life. All of these effects would increase with the more fermented cabbage I ingested, and likewise would be directly lessened with less.

My daughter too, after initially doing quite well and really making strides, seemed to acquire a cough and congestion and was more prone to sickness when eating cabbage or anything fermented, and I suspect it also had a hand in triggering her latest temporal seizure, it seemed more than just coincidence?

When we began she actually became sick with common colds less often and the cabbage seemed to be a protector of sorts…this association was also noticed for me and everyone in my family too, but that somehow changed and took on a new aspect. It no longer seems to prevent these colds, something has developed that is limiting this benefit. She has also developed a severe speech disfluency, a severe stutter that is directly linked to her consumption of fermented cabbage, or more precisely from what seems to be a reaction to the histamine in these foods. I’ve not heard or read anything about this connection with stuttering, which makes me question my observations but after several elimination tests it is absolutely clear that it’s directly related in some way. Her stuttering becomes less when she eats less of these foods and comes back in corresponding intensity to the amount of fermented food eaten — surprisingly we’re really only talking about a max. of an 1/8 cup per day, but it has this big effect.

The dilemma is if she is not getting these foods then she is also not realizing the other wonderful cognitive benefits from them, so it is a real and important quandary for us. In my situtation it is almost a matter of me being or not being able to do my work at a high level in order to support my family, it’s really this powerful of a situation!

Because she is following the Paleo/SCD/GAPS diet much of her food is high in histamine which is contributing to the overall load. This is probably why Paleo blogs seem to know more about histamine intolerance and seem to have a higher prevalence of it than others. We are trying to limit some of these high histamine foods but her food is already very limited due to her sensitivities and diet.

We’ve already gained so much that we believe in some ways “the sky is the limit”, we’ve come to expect a solution, a huge shift from our mainstream experience of masking or no solution. It’s been a very powerful ride and a wonderful awakening the last four years, I for one have lost a debilitating Ankylosing Spondylitis diagnosis, and my daughter a PDD diagnosis….and we know there are still more wonderful doors for us to open.

Because I and my daughter are similarly afflicted It seems like there is a strong genetic component to the sensitivities and intolerances, I can read her like a book…and it also seems like a solution to this histamine intolerance in particular could simply come down to being able to fully heal the gut or at least greatly reduce the hyperpermeability if possible – something that even with the strictest adherence to the Paleo diet for four years has heretofore seemed unable to heal by itself. I’m keen to hear any thoughts with regards to healing a leaky gut, as well as any other ideas you may have…be they centered on methylation, mitochondria, autoimmunity, epigenetics, effective testing or anything else.

I apologize for the long-winded nature of this, hopefully it will be of some interest to you and your readers and please don’t feel that any response has to match it in length, any insight of any brevity you can provide from your own experience, research or practice would be greatly appreciated and highly regarded.

Thanks for providing this wonderful blog!

Wow. Sounds like both you and your daughter have really been through a whole lot. Do you have a good doctor or functional medicine specialist to work with?

Is kraut the only fermented food in your and your daughter’s diet? The other possibility is an allergy to yeast rather than histamine sensitivity (hives sounds like a true allergy rather than a food intolerance). I guess either way, it ends up being histamine that’s the problem. I’m just wondering if other food sources of probiotics have the same reaction, so maybe you can get some benefit from switching to a supplement, at least temporarily. Have you tried soil-based probiotics? I really like Prescript-Assist and take it myself. I’m not sure what dose to suggest for your daughter. Many probiotics will suggest 1/4-1/2 the adult dose for kids but Prescript-Assist doesn’t have any kid specific recommendations on their label or their website.

It might be worth trying L-glutamine, if you aren’t already, to help restore gut barrier function. The dose used in scientific studies is 0.3g/kg to 0.5g/kg bodyweight, and it is best taken on an empty stomach. Also, if you are still eating nightshades, it would be worth considering giving them up for a while. DGL can also help restore gut barrier function, but I would only use a capsule and not a chewable or a lozenge, which might be hard to give a 5-year old (and with autoimmune disease, it’s important to take DGL and not whole licorice root).

Neural health is very sensitive to dietary omega-3 content (so is gut health). This is tricky because fish are some of the highest histamine foods but also the best sources of omega-3s. You could try a really high quality supplement and see how that goes. How does your daughter tolerate coconut oil? The medium chain triglycerides in it have been shown to be beneficial for dementia, so it might be worth increasing her intake to see if it helps (the reason why this works is because the MCTs are very easily converted into ketone bodies which neurons can use for fuel).

I guess the only other idea I have is to make sure you are eating those nutrient-dense super foods, like organ meat, vegetables, and fish (if the histamine isn’t a problem). Nutrient deficiencies are one of the biggest barriers to healing.

I don’t know if any of this is helpful or if this is all stuff you’ve played with. But I hope there’s at least something in here that’s a new idea for you to try!

I just re-read your comment above about DGL vs whole licorice root. Can you tell me more about this regarding autoimmune? I used to take licorice tea using root powder but stopped as I really didn’t like the taste. (Was trying to boost up my adrenals, my naturopath says my adrenals are weak) Any thoughts on this would be greatly appreciated!

I am no expert, but just read an article saying that L-glutamine supplements should possibly be avoided for those with seizures (having to do with the GABA-glutamate balance). It can tip the scale toward an excitatory response, which can cause more problems for some with neurological symptoms. I read some great information on some of this on Amy Yasko’s web site. Good Luck.

I just ran across your post and in case you’re notified of follow-up comments, would love to know if you’ve found any solutions. We are in a similar boat with my daughter reaction with stuttering to foods. There are multiple things that cause her stutter to get worse. I say worse because originally it would be infrequent only occurring with certain trigger foods. Over the past 8 months it’s pretty much constant, but certain foods exacerbate it terribly. Sauerkraut is one of them, fermented cod liver oil, blueberries, mandarins, corn to name a few. We’ve been pale for a year and a half and have just started up GAPS. Yet it appears the fermented veggie juice might be an issue. Trying to figure out how to heal as well with so many sensitivities.

Hello! I did a search on your site for “Co-enzyme Q 10″ and couldn’t find anything, then searched for “supplements” and found this page. What are your views on Q 10? I have been taking it for racing heart & slightly low BP and I think I’m reacting to it, the last few days my heart feels like it’s pounding harder than ever, even while lying in bed trying to sleep, I’ll be very tired and almost asleep but my heart will be pounding, and sometimes it feels like I can feel my pulse at the base of my throat. (I’ve had heart tests up the wazoo over the last couple years and nothing’s wrong) And I’ve had my insomnia get worse as well. So I’ve figured out yesterday that it might be the Q 10 and decided to stop it. I wanted to know what your view is on this supplement. I’m the one who also reacted with heart symptoms to coconut oil of all things, it made my heart race but it was my naturopath who clued me in about that (altering your absorption of calcium IIRC) As my naturopath said I seem to be very sensitive to supplements in my diet, even ones that should be very beneficial. I do take a good quality fish oil (Carlson’s I believe the brand is) Now I’m worried that I will start to react to that at some point! What do you think?

I think CoQ10 is an important nutrient, but like all nutrients, too much is not a good thing. It’s much harder to get too much when you focus on whole food sources (like heart meat in the case of CoQ10) compared to supplements. Plus, supplement have fillers and capsule ingredients which might be the really problem rather than the nutrient itself.

Sorry, what is ASD? Autism Spectrum Disorder? I think I may try to get a beef heart again. I did it once, took several weeks to get it from the Farmer’s Market as they forgot the first week and I had to go back the next week. And they delivered it frozen so I had to cook it all at once, I couldn’t cut & divide it without thawing it and refreezing it which didn’t seem like a good idea, it was tasty but by the time that heart stew was done I was sick of beef heart LOL I wound up throwing out the last bit as it took so long to eat it all. It was super tasty though, and not as tough as I thought. Yeah, no more supplements for me for awhile except the fish oil. Had you ever heard of anyone reacting to coconut oil or not being able to take it? I just hope I don’t start reacting to my fish oil as I want my Omega-3s from it. Thank you so much for your help! I love your site & your recipes!

Lol. A typo/autocorrect of the word “case”. That’s what happens when you try to reply to comments on an iPad while lying down in bed. Yes, I’ve heard of many people who have reactions to coconut oil. Mark Sisson believes that this reaction reflects a leaky gut and should go away when the gut heals. I’m not sure I’ve seen a very good explanation as to why it might be happening, although there is an interesting aspect of MCTs interacting with immune cells in the Peyer’s patches of the gut (parts of the gut with particularly high density of immune cells/tissues and particularly thin mucus layer designed to allow the body to “sample” the environment in the gut to keep a lookout for infections etc.) and potentially driving IgA antibody production (while also having a huge variety of antiinflammatory effects and improving the mucus barrier, which is why it’s a complicated question to answer).

Oh I see. Well I’m glad to know I’m not the only one who can’t take it! I kept reading all kinds of sites about it saying that it’s great, everybody should be taking liberal doses of it, etc. wondering if I was the only one who had a bad reaction! I still use it in my hair but that’s it!

Are all nuts high in histamine ? I think i read somewhere that almonds were lower in histamine, is that correct or do you recommend staying away from all nuts ?

Nuts are not high in histamine, but they are problematic for those with autoimmune diseases in other ways (mostly phytic acid, protease inhibitors, and high omega-6 content).

Ok thank you :) You mention coffee as high in histamine… I’ve mostly seen black & green tea mentioned as high in histamine like in Chris Kresser’s article: http://chriskresser.com/headaches-hives-and-heartburn-could-histamine-be-the-cause, where did you find info about coffee ? I’ve given up mostly all the high histamine foods on your list but giving up coffee is the hardest part!

Thank you for this amazing blog, it has helped me more than all the doctors I’ve seen and they are many!

I can hardly wait for your book to come out! It’s going to fill a major hole in the autoimmune canon. One minor typo above: Vibrio, not Vibro ?

Very interesting and could explain something that’s recently been happening to me.

I am fine with pro biotics and recently, I made sauerkraut and ate about a tablespoon’s worth. I could feel my guts were happy with it but 20 minutes later, I was itchy all over.

Tried again a few days later – same thing happened. A friend recommended trying a smaller amount (she says fermented veg contain much much more pro bitoics than supplements). I tried one strand of cabbage, and no itching. I’m wondering if what you are talking about above is what is happening to my body?

I am wondering if you know much about MTHFR and how it relates to histamine intolerance as well as autoimmune conditions in general? When I began researching HI, I came across this and it seems relevant to those of us with chronic conditions.

My understanding of MTHFR has more to do with liver function and HPA-axis/neurotransmitter stuff. Certainly, if you have one of the gene variants of MTHFR that makes it less effective, you’ll want to really focus on increasing vitamins B6,9, and 12.

I was wondering if that connection with the liver would contribute to a person’s (in)ability to detoxify. If your detox is impaired then toxins are building up and possibly contributing to gut issues and other conditions?

It is completely about your body’s ability to detoxify. If you have a MTHFR gene mutation, your body cannot convert vitamin B-12 or Folic Acid into it’s active form. You need to take the active form of B-12 (methyl) and B-9. There can be a lot of side effects (depending on how compromised your system is), so you should go slow and do some more research. Many individuals believe that MTHFR is a huge contributor to chronic illness and our pre-disposition to it. I read earlier in these comments that rest and good diet could help methylation (detox), but I don’t believe that to be true. You will need the right supplements.

Hi Sarah, I have found your post on histamine intolerance And it was The same symptoms my husband has been experiencing. He has severe asthma and sinusitis and have had about five operations To remove polyps in his nose He also can’t smell We have noticed that some foods cause is his asthma to flareup or give him a runny nose He also sometimes will have hives after eating Something He has decided to follow a Low histamine diet and he’s been on it for a week The other day he had duck for dinner and had some dried mango and Later noticed He had a hive on his face Although I try to look it up and Couldn’t find anything on it I was wondering If you knew whether there could be a cause for or whether Duck or Dried mango are high histamine Foods. Many thanks Marina

I haven’t seen duck or dried mango listed specifically, but it has a lot to do with how it’s prepared, so it’s possible any food could have high histamine content if it hasn’t been stored properly.

Thank you very much, we will try and see if it happens again. and maybe just avoid it in future.
many thanks Sarah, I appreciate your response!

I’ve read conflicting information about N-Acetyl Cysteine and histamine reactions. Some doctors apparently use it for histamine reactions, but I’ve also read that it may block DAO. Should you take it if you suspect you have histamine intolerance or does it make things worse? I’m finding this whole low histamine thing pretty confusing and frustrating. I feel like I can’t eat much of anything and am finding myself only eating about 500 calories a day lately, which isn’t good.

No, 500 calories a day is not good! Unfortunately, I don’t know the answer to your question about N-Acetyl Cysteine. Have you checked out Chris Kresser’s site to see if he has an answer (he would be better equipped to answer that question that I). I’ve seen some information that high vitamin C can blunt the histamine response, but it’s also controversial.

Thanks Sarah, I’m reading everything I can find, Chris Kresser’s site included, I just seem to be reacting to everything and it’s so frustrating to go from feeling so much better for months to having reactions again. I’d not had one in over a year, so I think I’m getting a bit of food phobia. Over the last 11 days it’s begun to feel like I look at food and react. ;) I appreciate your response.

Thank you for your blog!!!! Amine and histamine overlaod are a huge issue for my daughter, and a semi-big issue for me. She cannot tolerate any fish oils or coconut oil, so it is hard to get enough fat into her diet (also egg and dairy allergic or intolerant, but we hope to clear those in the future), and EFAs in particular. We rely on high-quality meats, but still not enough fat or omegas on a daily basis. I was thinking of trying MCT oil for healthy fat (although no EFAs), but it is derived from coconut oil which she handles very poorly. same for palm oil. Do you know if MCT oil is lower in histamines than virgin coconut oil? It would be a big help if so. Thanks in advance!

Hi there. A great blog. I have a quick question regarding omega 3 supplementation for inflammatory assistance. Which oil can you recommend? Thank you
Christine

Kno
Please telll me what you know abouT sardines and histamines. I was eating the canned ones In water but stopped because every list says too high In histamines. You mention they may not be. Please explain and thank you for your adviCe.:)

The histamines come from if the sardines aren’t chilled fast enough after being removed from the water, which is why it varies from one company to the next. If you’re super sensitive, you probably should avoid them, but otherwise, just try different brands.

OMG this list is an exact list of my intolerances. Glad to know all these foods have something in common. It makes sense now. I thought I was crazy so did my family. I had this since I was small on top of my dairy allergy. Can’t wait for the release of your book. I’m learning so much and want to get some testing done to help me heal. So far AIP has helped my gut issues but I still have eczema and scalp issues, kp on arms and legs and also sinus stuff.

I know you said that you can’t find any evidence on broth being a problem, but many other sites I have seen mention that slow-cooking is a problem. The only thing that’s keeping me from doing a low histamine approach (which I think is the last tweak I have left to try) is that as a grad student, I rely on leftovers 6 days of the week. I don’t eat most of the above foods anyway. Prior to purchasing a half hog a few weeks ago, I ate canned fish twice a week, a fermented vegetable once a week, and pork maybe once every week or two, but my symptoms are pretty constant and don’t get noticeably worse after those meals. Since Thanksgiving, I’ve been eating pork at least once a day and was trying to be better about FCLO and fermented foods in general. My allergies have been significantly worse but I was chalking it up to spending less time outside and increased stress of finals (and dairy and eggs on Thanksgiving).

If I’m sourcing low histamine meat well, should I be concerned that slow-cooking and cooked leftovers in my fridge for days have much higher histamine levels?

I have never been able to find a reference for cooking methods increasing histamines. There are a few papers looking at processing or storage and the effects on biogenic amines. This paper http://www.ncbi.nlm.nih.gov/pubmed/23163937 shows that no matter how you cook dry cured sausage, you reduce the amount of biogenic amines compared to raw (although they don’t slow cook). Given just how little histamine there can be in meat (especially compared to fermented meats and fish), my understanding from the scientific literature is it should be fine no matter how it’s cooked.

hi there

Such a great article but I am so confused. I have ordered your book but not got it yet. I am sure I am histamine intolerant so are you saying I shouldn’t eat bone broth, fermented foods, etc aren’t these the major items in your diet plan? If I don’t eat any fermented foods or drinks how to I get the probotics needed to heal my gut?

I am really confused-please help

Histamine intolerance is an extra complication, usually caused by a damaged gut and/or gut dysbiosis. You should avoid any food that you have a noticeable reaction to. Probiotic supplements are your best bet for now. Also, medium chain triglycerides like what’s in coconut oil can really help. It should get better as your gut heals.

Is coffee at the top of the list to avoid if you have eczema (assuming it is histamine-related)? And chocolate? Are there any others, say, in the “Top 5″ to avoid while having symptoms of possible HI?

Thanks for your link to my coffee question. I know teas are limited because of their fermentation, but is white tea ok in moderation? I believe it is the least processed of all tea; in fact, I believe it is only lightly dried before packing. Any information would be helpful. Thank you!

Someone else asked this question recently, and Sarah’s answer was: “I think a cup or two of black, green or white tea a day should be okay for most people. Just make sure to be really aware of how you are handling stress and how you are feeling.” Caffeine is discussed in The Paleo Approach. — Tamar, Sarah’s assistant

sorry one more question you mention you shouldn’t eat fish in the articles but then you talk about it and eating it 3 or 4 times a week. Should you do this even if you have histamine intolerance?

Different fish will have different histamine levels. Some studies show sardines and tuna have histamine and some don’t. So, I would recommend cautiously trying some premium brands (like Crowne Prince) and see if you have a reaction.

What is a good/clean source of collagen? Many are coming from China and I refuse to purchase them.

Thank you for the great infomaion.

Is coconut milk Kefir high in histamine?

Also, ive seen reports saying that cooked meat increases in histamine over time. How should it be properly prepared and stored (leftovers)? Where I live, I cannot get freshly killed fish, only the stuff sold in cans, the freezer, or the deli at whole foods. Same goes for poultry. Any advice on how to pick the least histamine offensive meats?

And is the collagen product low histamine? I know I react to the gelatin badly

I don’t know about coconut kefir or collagen. There have been no systematic studies testing histamine levels in them. I’ve heard that about leftovers too, but cant find any scientific studies to confirm. I’ve heard the recommendation to just not do leftovers if you have histamine tolerance, but again, I can’t confirm that with a scientific paper. As for canned seafood, different brands will have different histamine levels. I would suggest sticking with premium brands and testing cautiously to find one that works for you.

I’ve been dealing with histamine intolerance for the last four or so months & one thing I couldn’t stand the idea of was not getting use of my leftovers. I put my leftovers in glass jars as soon as I’m able (ideally while still hot) & stick them straight in the freezer. Than when I go to eat them- I take straight from freezer & cook- no defrosting in fridge or whatever first. Doing this I’ve personally had zero issues- & I’m unfortunately fairly sensitive

Great article and one that I was actually researching for answers yesterday…I started Paleo about 2 months ago, love it, as an added bonus so far I haven’t had seasonal allergies yet which I always get this time of year. However I went on a brisk walk yesterday and 15 minutes in started with a histamine reaction, hives on my legs and intense need to scratch them…this always happens when I walk or run. The part I’m confused on is I do eat fish weekly, salmon and canned sardines, also avocado, coffee and most of the other “histamine” foods you talk about but never get a reaction during or after eating them, only when I get my body temperature up from walking or running. I am wondering if you found any information that ties into what you are explaining above…do need to take out all those “histamine” trigger foods? Thank you for such an indepth study…when the doctor tried to explain it to me I looked at him like it was a foreign language…this breaks it down so much more for me.

Having allergies is a little different to having histamine intolerance and many of the foods here (especially seafood, but also fermented vegetables) contain nutrients that can actually help regulate the immune system. There is a condition called exercise-induced anaphylaxis in which intense exercise causes a leaky gut and allows food particles to enter the body and stimulate the immune system.

Samantha, from what I have read, heat, being hot, and even being in direct sunlight can trigger symptoms in folks who have Mast Cell Activation Disorder (MCAD), also called Mast Cell Activation Syndrome (MCAS). Dr. Theoharis Theoharides and Dr. Mariana Castells are experts in the disorder and you may find some helpful information by searching their names. I know they both have You Tube presentations.

A wonderful blog topic. I was diagnosed 6 years ago with idiopathic anaphylaxis (at the Mayo Clinic), and have to use my epi pen about 6 times a year. My allergist told me that the anaphylaxis will “go away” as quickly as it started, some day, and that Dr’s don’t know what start or end this. Your writing and research give me hope that my new paleo approach will have an influence on reducing or stopping this process.

I figured out I had a histamine intolerance a few months ago when the AIP diet caused my symptoms to blow up to a whole new level of badness I’d never experienced before- culminating in hives covering my whole body. Very not fun. I cut myself down to as low histamine diet as I could & through trial & error brought my symptoms back under control & than reduced them to almost nothing! I have celiac & despite being gluten free for almost three years I suffered with almost daily gut pain, bleeding, & D. But the last month I’ve had none of that! & my cronic daily headaches have reduced to mayb one or two mild ones a week if that! So happy! I’ve even managed to reintroduce a couple slightly higher histamine food with success. The down side is that my diet is restricted to a level I can’t help but consider unhealthy & I’ve started to see symptoms of that (leg cramps, etc). I do what I can to mitigate this with supplements or even eating some foods that cause uncomfortable but not terrible reactions but I consider this far from ideal. Before this latest way of eating I showed many symptoms I felt fit with someone suffering SIBO. Even histamine intolerance could be a symptom of that. So I’m wondering if it would be worth it for me to try the elemental diet. I’ve seen the recipe & while the process seems harsh and not a lot of fun- I’m sure I could do it if it could help. I figured afterward I could ease myself back onto the foods I’m eating now & starting trying to reintroduce new foods starting with the lowest sugar & FODMAP & working outward. Is it worth trying? Or am I better off sticking to what I’m doing now- which is working- though slowly?

Hi Sarah! Hope you are having a great day! :):):) I am a huge fan of yours (even before the book came out!). I have a question – i am hashimoto person. You have mentioned that with thyroid problems, one should stick to low-histamine diet. I am really confused bc in order for us to heal our guts, we should consume bone broth. But if bone broth contains lots of histamine, then how are we supposed to heal our guts if we cannot consume it? Also, to support the hypothyroid and the liver, we need to eat protein. But if meat is high in histamine, how are we supposed to heal? I am trying to include nutrients and not exclude but have been so confused with the entire histamine-gut-thyroid connection. Can you please let me know your thoughts. I know you have been extremely busy with the book, the tours, the wound, the consulting project, etc. but i truly hope to hear from you. thank you, Sarah! Have an amazing day and keep smiling!

Sarah does not recommend a low-histamine diet for thyroid patients, only relates that poor thyroid function can cause histamine problems. If you suspect histamine intolerance, you may find that it improves when your thyroid hormones are corrected. – Christina, Sarah’s assistant

You mention mast cell activation ~ I have been reading about Mast Cell Activation Syndrome as I suspect I have Postural Orthostatic Tachycardia Syndrome. Can you elaborate more on what research you have found that connects histamine and mast cell activation? I find this fascinating yet at the same time very deep and confusing at times. So far I can’t connect any specific food to my symptoms, they just seem to come & go. At the moment I am struggling with very bad bloating and an inability to lose weight despite eating basically meat & fats with one salad a day and tea with soy milk. Could the soy be a histamine problem?

Well, mast cells are one of the two cells types that secrete histamine when activated. But, I’m afraid that MCAS isn’t something I know a lot about.

As for soy, there’s lots of ways that can be a problem, food sensitivities, immune activation by soy lectin, the phytoestrogens…

I would suggest having your thyroid checked (and maybe hormones at the same time). The combination of really low carb and not losing weight is one of the ways low thyroid presents itself. I would also suggest talking about digestive support supplements with your healthcare provider.

Yes, I’ve had my thyroid tested many times, it’s always fine, my TSH is always at the low end of the range which should mean it’s not having to stimulate my thyroid if it were sluggish. I’ve been meaning to cut out the soy milk for ever, this should give me the impetus to do it! Now I suspect the greens powder I forgot to mention I was taking to ‘clean the pipes’, it’s got Irish Moss in it, now I’ve just read an article about carrageenan and water retention! I shoot myself in the foot every time I turn around, it seems!

Hi Sarah, I am extremely intolerant to any amines. Even the smallest amount of coconut oil or any coconut product will give me a severe migraine and even just one fish oil supplement will put me in bed with a migraine for days. I have been trying desperately to follow the Paleo approach but I’m finding it difficult to balance my omega 3′s to omega 6′s as you say when I can’t eat coconut, dairy or fish oil. Can you please recommend what I should be eating to help balance my omega levels? It’s the only way I can see my gut healing and possibly healing this migraine and chronic fatigue hell I’ve lived with for so long. Please help as doctors don’t seem to be able to. They just throw more medication at me and it’s only exacerbating the problem.

Sarah,
I am trying to figure out why my Raynaud’s phenomenon has worsened since going on a paleo diet. After much trial and research, I feel that I have flares of Raynaud’s after consuming with high histamine.

Have you found any research linking histamine intolerance with Raynaud’s?

I get heart palpitations from vitamin e, and fish oil, but not krill oil for some reason… No idea why until reading this…. Being an ex eczema sufferer ( being strict on not eating night shades has helped. Great deal … And coating my body in cold pressed oil daily ) this is all very interesting!

Great article! Looking forward to reading more! In all your research did you come across anyone with Urticaria Pigmentosa? My 6 year old son suffers from this which means he has pigmented spots all over his body and in these spots is where all the mast cells are located. Mast cells produce histamine. When he eats high histamine foods, these spots turn into hives. He takes Zyrtec daily and his condition is mild compared to others i have come across. Just wondering if the Paleo approach could help?

thanx for a really helpful post. can u tell where these foods stand – fish oil, mango(green and ripe), green bananas, chicken skin (i get fresh chicken from the butcher’s) and moringa leaves (how safe are they to be consumed regularly) ???

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