The Low Histamine Diet

Podcast Transcript

Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end-to-end.

Hi again, everyone, and welcome to another episode of Butts & Guts. I'm your host, Dr. Scott Steele, colorectal surgeon and president of the main campus here at the Cleveland Clinic in beautiful Cleveland, Ohio. It's always great to welcome back a returning guest and very, very pleased to have Amanda Igel MS, RD, LD, who is a registered dietician here at the Cleveland Clinic. Amanda, welcome back to Butts & Guts.

Amanda Igel MS, RD, LD: Well, thanks for having me again.

Dr. Scott Steele: So today we're going to talk about low histamine diet, but before we do that, and for people who don't remember your episode, I guess it's been five years or so now, we'll give us a little bit of background about yourself, where you're from, and how did it come to the point that you're here at the Cleveland Clinic?

Amanda Igel MS, RD, LD: All righty. Well, I grew up in Cleveland on the East side and I currently live on the West side, so I did all of my schooling here. I went to Case Western Reserve University and did my dietetic internship at the Louis Stokes VA in Cleveland. I came to Main Campus in 2014 and did mostly inpatient at that time, working on various medical surgical floors. And then in the past year, I transitioned to outpatient where now I cover the enteral tube feeding clinic and our neuro GI dysmotility clinic.

Dr. Scott Steele: So for people who don't understand what a dietician does, give me a little bit of background about your niche and what that profession entails.

Amanda Igel MS, RD, LD: Well, dieticians, what we do is something called medical nutrition therapy. So basically, we look in an assessment of your nutritional status for the most part, do some physical exams, look at labs, look at your medical history, and then we create a plan of nutrition around the things that may be problematic or that we're trying to make better.

Dr. Scott Steele: That's fantastic. And so again, we're going to talk today about a low histamine diet. So that might be a new term for many of the listeners out there. So to start, can you share at a high level what a low histamine diet is and maybe even start with easier. What's a histamine?

Amanda Igel MS, RD, LD: So histamine is a protein that your immune cells produce to help you, to help your immune system respond to environmental allergy triggers. So for example, if you have an allergy to a certain food, your immune system releases histamine to protect the body from what it perceives as a threat. That's why your throat may close up. It's the way the body of preventing more from that food being ingested. So on the flip side, histamine intolerance is not the same as a food allergy since the immune cells are not triggered when a certain food is eaten.

Dr. Scott Steele: So what are some of the symptoms of having an overabundance of histamine and what's a low histamine diet?

Amanda Igel MS, RD, LD: A low histamine diet. It's used to treat those who have something called a suspected histamine intolerance. So not an allergy but an intolerance. So our bodies contain many digestive enzymes to break down sugars, protein, fats, and everything that we eat. So it's kind of similar to something like a lactose intolerance. So if you don't have enough of the enzyme lactase to break down the milk sugar for digestion, you build it up in the body and then you have your GI symptoms. It's a similar concept for histamine intolerance. So there's something in your body that you don't have enough of the enzyme called diamine oxidase to break down histamine, and without enough of that diamine oxidase, histamine can build up to high levels and then produce allergy-like symptoms through the body.

So histamine is present in a wide variety of foods in highly variable concentrations. So there's not, like when you look at a food label, this is how much histamine is contained in this food. It's very variable and it depends on a variety of factors of how fresh the food is. So low histamine diet limits both foods that are naturally higher in histamine, usually fermented foods or something which bacteria can produce histamine, and then the low histamine diet also limits certain foods containing high levels of proteins that may inhibit the breakdown of histamine.

Dr. Scott Steele: Okay. So I'm listening out there and I'm thinking to myself, "How do I know if I got a histamine intolerance or not" and so what are some of those symptoms like if I got an overabundance of histamine?

Amanda Igel MS, RD, LD: Generally, the most present are GI symptoms. So sometimes, you'll get abdominal distension, early satiety, diarrhea, abdominal pain, nausea and vomiting, and constipation. Sometimes, you'll also get more allergic-type reactions after eating, such as nasal congestion, dizziness, heart palpitations, headaches, and skin rashes. So even though you have all of these different abdominal symptoms and allergy symptoms, it's important that we're not just going to a histamine intolerance right away so that you need to have this ruled out by a GI or an allergy specialist to rule out those causes of those symptoms.

Dr. Scott Steele: So kind of speaking of that, we've spoken about IBD, inflammatory bowel disease, celiac disease here on Butts & Guts in the past. And so are there specific conditions like that that may mimic histamine intolerance and would that diet work in those conditions as well?

Amanda Igel MS, RD, LD: So histamine intolerance differs from other GI conditions since food compounds that drive the GI symptoms are usually accompanied by allergic-type reactions. So histamine intolerance can vary by season, similar to someone with environmental allergies. A low histamine diet is not used for other GI conditions, mainly because GI symptoms are usually triggered by other mechanisms that have nothing to do with the histamine pathway. Low histamine is not effective in people with mast cells disorders as well just because there's just way too much variability and usually, mast cells are driven by other allergens in the environment as well and it's impossible to eliminate all histamine in both your food and the environment. So these conditions for mast cell conditions are usually treated with antihistamines or mast cell stabilizers.

Dr. Scott Steele: So truth or myth, truth or myth, a low histamine diet is a great diet to follow if someone is looking to lose weight.

Amanda Igel MS, RD, LD: A big myth. So low histamine diet is purely used to improve symptoms of those suspected to have a histamine intolerance.

Dr. Scott Steele: So give me an example of a low histamine diet. Are there foods that people should incorporate into this diet or on the counter side, foods that they should avoid and is there any other guidelines or best practices that a patient should follow?

Amanda Igel MS, RD, LD: So if you Google low histamine diet, you're going to get like a thousand different types of diets. There's really no consensus on what exactly the low histamine diet should consist of since histamine levels and food can vary due to freshness, environmental factors and tolerance levels. Bottom line for the low histamine diet is fresh is best. So flash freezing and boiling foods can also decrease the production of histamine. You want to avoid fermented and aged foods as well as food preservatives like containing benzoates and sulfites are some of the biggest culprits that should be excluded first. Most histamine diets also recommend limiting spinach, tomato, citrus, and strawberries because they can limit that diamine oxidase enzyme activity. Medications can also inhibit the diamine oxidase activity, so it's best to discuss these with your doctor or pharmacist to limit these types of medications.

Dr. Scott Steele: So when people out there are listening to this, do you recommend that everybody try a low histamine diet?

Amanda Igel MS, RD, LD: No, that's also a myth. A low histamine diet is not to be beneficial for anyone who's not suspected to have a histamine intolerance. Keep in mind that those with food allergies should only avoid the specific foods that they're allergic to.

Dr. Scott Steele: So what are the benefits of working? We started off the show by just asking a little bit more about what a registered dietician does. So what are the benefits of working with an RD when searching for ways to treat this possible histamine imbalance?

Amanda Igel MS, RD, LD: Especially because if you do Google low histamine diet, you're going to come up with many different iterations. And if you try to do this by yourself, oftentimes, you may be without some kind of nutrients or you may be lacking something that could be detrimental to your nutritional health and then your health in general. So a dietician who specifically specializes in gastrointestinal disorders is usually the best person to help develop a personalized diet plan to help prevent any unnecessary restrictions. And then also, people that may be following other diet restrictions such as gluten or have an underlying disordered eating, it's important that a dietician also follow them to make sure that they're managing all of those different aspects of the diet.

Dr. Scott Steele: Is this low histamine diet something that you need to stay on the rest of your life or is it something that you just bridge and then all of a sudden, your body gets in a different homeostatic space or how does that work?

Amanda Igel MS, RD, LD: Usually, it can be a lifelong thing. It really just depends on the amount of that diamine oxidase activity that you have. So there are supplements that you can take that have diamine oxidase in them, but everybody responds a little bit different just like lactose intolerance, lactase enzymes are available, but everyone's a little bit different as far as their tolerance and then how much or how little that they need to eat histamine.

Dr. Scott Steele: So are there any advancements on the horizon when it comes to treating this histamine intolerance, especially through diet?

Amanda Igel MS, RD, LD: Well, the first step would be creating a specific diagnostic criteria for histamine intolerance. You can measure the plasma diamine oxidase activity, but it's not sufficient as other underlying conditions like IBD can lower that DAO activity as well. Most get diagnosed using a histamine exclusion diet for four to eight weeks and recording symptoms. So we put you on a low histamine diet, if it's improving your GI symptoms and then any allergy symptoms, it's usually that. Although the low histamine diet has shown promising results in symptom improvement in some small studies, larger studies are needed both to define parameters for the low histamine diet and to prove effectiveness of the diet on a larger scale. Finally, oral supplementation of the diamine oxidase enzymes needs to be standardized. So usually, those contents differ in variability of their effectiveness.

Dr. Scott Steele: So I'm a patient listening here and I'm going to come see you in clinic. What can I expect to do? Are you going to take a bunch of blood for me? Do I got to bring in what I eat during a day or walk me through what a typical visit, what a typical evaluation is like?

Amanda Igel MS, RD, LD: So when you come to see me in any of my clinics, usually it's for a specific reason, whether in my case, it's for tube feedings or for some kind of gastrointestinal distress. I usually go through a medical history to see what has been tested, what's been done. We go over things like what you typically would eat in a day, any fluid amounts. I look at labs. I will do something called a nutrition-focused physical exam where we're just examining areas for fat and muscle loss, looking for vitamin deficiencies, and then from there, creating a plan of how can we either improve the condition that you're coming in for or improve your nutrition.

Dr. Scott Steele: Fantastic. So now it's time for our quick hitters, a chance to get to know you a little bit better. So first of all, what was your first car?

Amanda Igel MS, RD, LD: Oh, my first car was a Geo Prizm.

Dr. Scott Steele: Fantastic. And so are you salt or are you sweet?

Amanda Igel MS, RD, LD: Oh, definitely salt.

Dr. Scott Steele: Fantastic. And so can you tell me about a place that you have either upcoming or something on your bucket list you're like, "If I won some money, I would go there." Where would there be?

Amanda Igel MS, RD, LD: Anywhere in the Pacific islands, any of those places, probably either Tahiti or New Zealand.

Dr. Scott Steele: Fantastic. And so if you could go back in time, maybe at the end of your high school and give yourself a little bit of advice, what advice would you give yourself?

Amanda Igel MS, RD, LD: Oh, that's a good question. I would say don't worry. Be happy.

Dr. Scott Steele: Fantastic. And so give us a final take on message to our listeners regarding kind of just this entirety about a low histamine diet.

Amanda Igel MS, RD, LD: So a low histamine diet is not a no histamine diet. It limits the ingestion of histamine. However, it's impossible to determine the exact histamine content of various foods. This diet is only used to treat suspected histamine intolerance once all other GI conditions, mast cell disorders, and food allergies have been ruled out. There's no known benefit from following this diet for any other reason. And research regarding histamine intolerance and low histamine diet is lacking, so please work with a registered dietitian familiar with this diet or if you're suspected to have a histamine intolerance.

Dr. Scott Steele: Fresh is best.

Amanda Igel MS, RD, LD: Fresh is best.

Dr. Scott Steele: So to learn more about nutrition therapy at the Cleveland Clinic, please visit clevelandclinic.org/nutrition. That's clevelandclinic.org/nutrition. You can also call 216.444.7000. That's 216.444.7000.

Amanda, thanks again for joining us on Butts & Guts.

Amanda Igel MS, RD, LD: Thank you.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.