The “OH Histamine” Diet

Yeah, you read that right. It says “OH Histamine.” As in, a doting and gushing and favoring admirer. As in, “Ohhhh Histamine, you are absolutely mahhhvelous!”

The mast cell activation syndrome (MCAS) patient community has been focused on the trend of a low-histamine diet for the past decade as the phrase “histamine intolerance” has been thrown around more and more. When patients are diagnosed with MCAS, they are often instructed by their doctors to start a low-histamine diet.

But where does this come from? What is the goal?

The logic behind the diet is to eliminate the build-up of histamine, a chemical mediator released by mast cells, which can also be ingested in foods we eat. Certain foods and beverages (such as aged cheese, alcohol, and cured meats, for example) are notably higher in histamine content and more likely to trigger reactions. Leftovers and fermented foods are other sources of histamine build-up. Other foods are avoided because they may not be high in histamine themselves but are considered “histamine liberators.” The idea in reducing the intake is to decrease the overall load in the body.

A bucket analogy is often used, where you can imagine that a number of environmental factors lead to a build-up of histamine in the system, which is often compounded by genetic predispositions that may make it difficult for the body to produce the enzymes (such as diamine oxidase, or “DAO”) that break down histamine. The offending food may just be that little extra bit that causes the bucket contents to spill-over, which can cause the patient to experience allergic-type symptoms during meals (or at other times). So, the logic is, reduce the amount of ingested histamine to prevent those reactions from occurring and to get the bucket baseline to lower levels.

Dr. Janice Joneja and The Swiss Interest Group for Histamine Intolerance (SIGHI) are some popular web resources for patients who have issues with histamine. Doctor Jill Carnahan also has some resources for patients who are doing elimination diets or low histamine trials. However, despite their popularity, the low histamine diet remains a controversial point.

Chew on this for a minute: what if we have it all backwards? What if focusing on the “no’s” in our lives is actually creating more stress for the body?

Furthermore, it seems like patients on this diet commonly end up with a tiny handful of “safe” foods. (I can attest: I used to be one of them!) I can’t help but cringe when I see patients who are eating additive-laden processed foods and eliminating fruits and vegetables blindly because they are following advice to try the low-histamine diet.

Is it healthy to be down to a small number of “safe” foods?

Can the low-histamine diet actually harm the body by reducing healing nutrients and helpful dietary options? Is it truly healthy to eliminate an avocado, citrus fruit, spinach, tomato or a banana from one’s diet simply because it’s on some list on the internet? And further, does long-term avoidance of important nutrients set one up for more health problems down the road? Why are the lists all over the map in terms of histamine numbers?

And perhaps most importantly,

Is the low-histamine diet simply “putting a band-aid” on symptoms, while the underlying MCAS cause continues to go on undeterred?

I obviously had a lot of questions, so I decided to dive into the literature to see if there was any scientific support behind it.

I was unable to find any studies evaluating the efficacy of a low-histamine diet in the MCAD population.

There are some literature sources that support the use of a low-histamine diet for other patient populations. A case study of a 6-year-old child with atopic dermatitis noted a reduction in symptoms when he followed a low-histamine diet.¹ A 2017 study found that 61% of patients with chronic spontaneous urticaria had a clinically significant reduction in symptoms following a 3-week low-histamine diet, but there were no changes in DAO levels.²

A 2007 article published in the American Journal of Clinical Nutrition by Maintz & Novak is one of the most referenced authorities on the topic.³ The 2007 authors recommend that patients with histamine intolerance avoid “alcohol and long-ripened or fermented (and therefore histamine-rich) food, such as aged cheese, cured meat, and yeast products; histamine-rich food, such as spinach or tomatoes; or histamine liberators, such as citrus fruit.”³ In the same “histamine intolerant” patient population, they claimed that “a histamine-free diet, if necessary, supported by antihistamines or the substitution of DAO, leads to an improvement of symptoms.”³

However, the 2007 article did not cite ample research to back up the idea that a low histamine diet (in isolation) is clinically supported.

They referenced one study (conducted by one of the same main authors) on a low histamine diet for 2 weeks in patients with atopic eczema.⁴ However, this study was methodologically flawed as it had a sample size of 17 patients, a very short study window, and more importantly, it included a combination of oral antihistamines and a low-histamine diet in all patients studied for two weeks. Thus, one cannot conclude from the results that the diet was what alleviated symptoms.

The 2007 review cited two additional studies of migraine headache patients that responded well to a low-histamine diet (one of which was only available in German).^5-6 In the English-language publication, 45 patients with either chronic headaches or food/wine sensitivity trialed a diet that eliminated fish, cheese, hard cured sausages, pickled cabbage and alcoholic beverages. After one month, 73% of patients had a statistically significant improvement in symptoms, and eight patients (17.8%) were symptom-free.⁵ Twelve patients (26.7%) had no response to the diet.⁵ However, the patients were not controlled in terms of their medication and anti-histamine intake.

Lastly, the 2007 review made their conclusion based off a study conducted in 2000 examining the effects of a low-histamine elimination diet on chronic idiopathic urticaria. The study included ten participants who conducted a three-week elimination diet (low-histamine in nature), followed by a ten-week re-introduction of foods every other day (also low-histamine in nature). After the three-week period, the authors reported that all subjects’ symptoms were reduced to some extent. After the 13-week period, 30% had complete remission of chronic urticaria symptoms, 30% had partial remission, and 40% had partial remission with transient relapses.⁷ Thus, 70% of patients still had urticaria symptoms at the end of the study. They did note a decrease in plasma histamine levels in all patients at the end of the study, but DAO and gastrointestinal permeability measures were unchanged.⁷ There were some limitations to this study: the low sample size, a lack of standardization in terms of dietary protocols, and subjective outcome measure reporting. The authors also noted that “we cannot establish whether clinical improvement was due to low levels of histamine or low levels of offending antigens in the diet.”⁷

In summary, there are some examples of literature support for a low histamine diet in patient populations of chronic idiopathic urticaria, headaches, atopic eczema and dermatitis, and patients with histamine intolerance symptoms.

However, several studies had methodological flaws and potential confounding variables such as anti-histamine usage. None of the studies were randomized controlled trials or systematic reviews, and none of them addressed MCAS specifically, highlighting the need for more research in this area.

A 2017 review article by German researchers supports the standpoint that current research is inconclusive about the utility of a low histamine diet for histamine intolerance.⁸ “The scientific evidence to support the postulated link between ingestion of histamine and adverse reactions is limited, and a reliable laboratory test for objective diagnosis is lacking.”⁸

A 2016 review article noted some concerns with the low-histamine diet as a form of therapy. Martin and colleagues discussed the importance of establishing a proper histamine baseline level (as opposed to a completely histamine-devoid diet) and working to improve dietary options over time.⁹

The 2017 review article also admonished restrictive diets for patients who have symptoms of histamine intolerance.

“A diagnostic work-up, combined with individualized nutritional therapy that focuses primarily on nutrient optimization and helps patients reliably to differentiate symptoms, is to be preferred over generalized, restrictive diets.”⁸

According to Reese et al (2017), “Some of the dietary recommendations that are currently circulating are not supported by scientific evidence. For example, numerous low-histamine diets prohibit foods that do not contain histamine (e.g., yeast), or encourage the avoidance of so-called “histamine liberators” (pharmacologically active substances that have a histamine-releasing effect), despite there being no reliable evidence of their existence in foods or of their clinical relevance in the onset of adverse food reactions. The inconsistent data on biogenic amines in foods make it difficult to issue safe recommendations on diagnosis and define treatment measures.”⁸

Reese and colleagues concluded in 2017, “The treatment approach should be largely guided by the individual tolerance of affected individuals. Generalized restrictions on food selection are only relevant for diagnostic purposes and do not help affected patients in the long term. More research is needed to establish the relevance of measuring biomarkers, risk factors in intestinal function and barrier, as well as the histamine dose that elicit pharmacological effects of histamine. Until then, expert nutritional counseling can help patients to avoid diets that result in an unnecessary reduction in their quality of life.”⁸

Here are some other reasons that I think the low-histamine diet is flawed:

• Focusing solely on histamine may be suboptimal management for a patient with MCAS. Histamine is only one of hundreds of chemical mediators released by mast cells. Not all patients with MCAS test high for histamine in blood and urine clinical tests.
• Patients are instructed to eliminate a huge number of foods, regardless of their individual tolerance to them. When patients may try to add them back in later on, they often find that they are no longer able to tolerate the food they had eliminated.
• The basis of making decisions to eliminate foods is flawed. Histamine numbers differ depending on a number of factors in the chain of handling, and there is great variability between sources on the internet and in studies.
• I believe that too much of a focus on numbers and “no” lists can be unhealthy in the diet. For someone who has MCAS, the combined list of the foods that one is truly allergic to, the ones that seem to trigger other mast cell symptoms, and the ones that are high in histamine, salicylates, etc. can eliminate a great deal of food options, leaving the diet devoid of nutrients that are important for healing.
• While foods may serve as the immediate trigger to a reaction, it’s wise to consider the other factors that may have caused the “bucket” to fill up and overflow. In my opinion, when I picture a pie chart, histamine is just one small slice of the whole picture and focusing solely on histamine may keep a patient in a vicious cycle of reactions and eliminations and a false sense of control that becomes a slippery slope into more dietary restrictions.
• We should be thinking smarter, not harder. We should be aiming to figure out the biggest (often hidden) underlying factors that are causing mast cells to be overactive and start there.

The OH Histamine Approach

• Eliminate all true allergens and foods that cause patient-specific reactions. (By no means am I suggesting that patients purposely trigger reactions. True allergens should always be avoided.)
• Complete a thorough assessment of environmental triggers and toxins and make drastic changes in those areas. Evaluate for mold in home/work and car environments, ensure that water and air are clean, evaluate health and beauty products, replace cleaning supplies with natural alternatives, remove other everyday sources of toxins (like plastics, dryer sheets, air fresheners, heavy metals, etc.) and reduce EMF exposure if possible. If possible, work with a functional medicine doctor or naturopath to help determine other individual-specific factors that may be chronically triggering mast cells (viruses, bacteria, etc.).
• For foods that are reacted to sporadically, keep in mind that in some cases, things like cross-contamination, temperature, additives and pesticides on non-organic produce could be triggering reactions instead of the food itself, (similar to how patients with MCAS may react to an excipient in a medication).
• Do not eliminate foods based on numbers, with the exception of a select few that tend to consistently be astronomically higher than the rest that may be good to eliminate anyway (like alcohol, cured meats, and aged cheese).
• Consider elimination diets only as a short-term way to identify trigger foods, but outside of a month (or less) of that trial, try to maintain diversity in the diet.
• A preservative or additive-free eating plan may be a good starting point for the patient with MCAS. Eliminating all processed foods, non-organic produce, gluten, grains, caffeine, refined sugar and dairy may also be beneficial for overall health and inflammation reduction.
• Embrace the beauty of a diet of colorful fruits and vegetables. Supplement the diet with natural histamine-lowering foods and consider herbal supplements (with your medical teams’ help, of course).

I acknowledge that my (controversial) personal opinions on this topic are just that – personal opinions.

Eliminating most histamine-containing foods caused me to feel slightly better for a number of days or weeks, but then I got sicker and down to very few “safe” foods. When I instead focused on eliminating viruses, mold exposure, chemical toxins, heavy metals, and other everyday triggers to my mast cells, I was able to re-introduce virtually all foods (except my few true anaphylactic allergies I’ve had my whole life) and was able to reduce my mast cell medications dramatically. I found it fascinating that the simple acts of leaving a water-damaged building, getting rid of my mold-exposed belongings, and following a toxin-binding program did way more to expand my food options than any of the dietary approaches I tried. The bottom line is, I would rather pre-emptively eliminate environmental hazards than reactively eliminate (healing) foods from my diet.

I understand that it’s not always so black and white, and I’m not a nutritionist. I am not intending to condemn patients who follow a low-histamine diet. And I certainly know that we are all different. Some patients are severely sick and eliminating histamine-contaminating foods may mean the difference between anaphylaxis and stability.

I do not think that the low-histamine diet makes logical sense for a long-term healing plan, and the scientific literature has yet to convince me otherwise. I believe the end-goal should be a well-balanced diet full of antioxidant and anti-inflammatory fruits and vegetables, regardless of their “histamine content” numbers. And as a whole, I believe that a “low-toxin diet” should always trump a focus on histamine in patients with MCAD.

References:

1. Chung, Bo Young, Soo Ick Cho, In Su Ahn, Hee Bong Lee, Hye One Kim, Chun Wook Park, and Cheol Heon Lee. “Treatment of atopic dermatitis with a low-histamine diet.” Annals of dermatology23, no. Suppl 1 (2011): S91-S95.
2. Wagner, N., D. Dirk, A. Peveling‐Oberhag, I. Reese, U. Rady‐Pizarro, H. Mitzel, and P. Staubach. “A Popular myth–low‐histamine diet improves chronic spontaneous urticaria–fact or fiction?.” Journal of the European Academy of Dermatology and Venereology31, no. 4 (2017): 650-655.
3. Maintz L, Novak N. Histamine and histamine intolerance. AM J Clin Nutr. 2007;85:1185-96.
4. Maintz, Laura, Said Benfadal, Jean-Pierre Allam, Tobias Hagemann, Rolf Fimmers, and Natalija Novak. “Evidence for a reduced histamine degradation capacity in a subgroup of patients with atopic eczema.” Journal of allergy and clinical immunology117, no. 5 (2006): 1106-1112.
5. Wantke, F., M. Götz, and R. Jarisch. “Histamine‐free diet: treatment of choice for histamine‐induced food intolerance and supporting treatment for chronical headaches.” Clinical & Experimental Allergy23, no. 12 (1993): 982-985.
6. Steinbrecher, I., and R. Jarisch. “Histamin und Kopfschmerz.” Allergologie28, no. 3 (2005): 85-91.
7. Guida, Bruna, C. De Martino, S. De Martino, Giovanni Tritto, Vicenzo Patella, R. Trio, C. D’Agostino, P. Pecoraro, and Luciano D’Agostino. “Histamine plasma levels and elimination diet in chronic idiopathic urticaria.” European journal of clinical nutrition54, no. 2 (2000): 155.
8. Reese, Imke, Barbara Ballmer-Weber, Kirsten Beyer, Thomas Fuchs, Jörg Kleine-Tebbe, Ludger Klimek, Ute Lepp et al. “German guideline for the management of adverse reactions to ingested histamine.” Allergo journal international26, no. 2 (2017): 72-79.
9. Martin, I. San Mauro, S. Brachero, and E. Garicano Vilar. “Histamine intolerance and dietary management: a complete review.” Allergologia et immunopathologia44, no. 5 (2016): 475-483.

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