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Dietary change

Definitions

Diet
Coloquially, diet is used to describe a strategy to reduce calory intake in order to control body weight. We do not use the expression as a synonym for a slimming cure but in a wider sense:
In general diet is a special type of alimentation where you consume a special selection of food in the long term or permanently. This includes the weight-reduction diet (short: reduction diet) as well as long-term and permanent dietary changes as supportive treatment for a disease (therapeutic diets). Every type of diet - be it for weight control or as supportive treatment - is based on a reduction or increase of a share of certain food components and/or a reduction or increase of the energy intake ("calories"). Certain types of diet require the complete avoidance of certain nutritional components (food allergies).

Elimination diet, histamine-elimination diet
A diet, where possibly all foods (in our case all foods with histamine potential) have to be cut out (= eliminated), we refer to as elimination diet (=omission diet).

Foods to be eliminated

Why are certain types of food badly tolerated?

On the page Disease > histamine intolerance we explain the pathological mechanisms of the disease and name the interference factors in the histamine metabolism. We derive that foods with histamine potential have to be avoided:

• Histamine-rich foods
• Histamine liberators
• Other biogenic amines (substrates that compete for DAO; some act similar to histamine)
• Degradation inhibitors (DAO inhibitors, HNMT inhibitors)

Food lists: What is well / badly tolerated?

It is more difficult to judge which foods will have to be avoided in case of HIT than with other intolerances. The transition between well and badly tolerated is gradual and depends on the amount ingested so that no well-definied limit can be determined. The intolerance is partly individual and depends on many factors (please refer to section "What you have to know before starting a diet"). Depending on individual susceptibilities, not all people affected have to follow the same diet or an equally strict diet. From our current state of knowledge we recommend the following multi-stage method to identify the right diet:

1. In order not to unnecessarily follow a limiting diet, you may start with the simplified elimination diet mentioned below, where you only cut out foods, which usually display a distinct histamine potential in most people affected.
2. If this is not suffient for reaching a satisfactory and stable symptom-free condition after a few weeks, we recommend you strictly follow the strict elimination diet, which usually allows even people who are very sensitive to histamine to achieve a condition without complaints.
3. Should this also be unsuccessful, you may have to consider that there may be other not yet recognized problems with your diet or other intolerances, allergies or underlying diseases. In that case, you may have to try a particularly radical rice and potatoes diet.

Of course, you may also start with the strict elimination diet or the rice and potato diet. That would be the most effective way to remove the discomforts as quickly as possible. The more radical and consequent the dietary change, the better you feel the reduction of symptoms. The effort is, however, considerable and you may limit yourself unneccessarily if you are not one of the highly susceptible individuals.

Important: It is not possible to compile a list of well-tolerated foods that is applicable to the same extent to all people affected. In the section "What you have to know before you start the diet") we describe why the delimitations between tolerated and not tolerated may not be the same for everybody. In general you may eat anything you want, even the foods that are labelled as "badly tolerated" as well as unlisted foods, as long as you do not have any negative symptoms or if you are prepared to accept minor discomfort from time to time.

Simplified elimination diet (NOT recommended!)

We have compiled a neat brochure of foods that should be avoided or on the other hand are acceptable during the simplified elimination diet. This leaflet on low-histamine diet may be downloaded here:
SIGHI-Leaflet_HistamineEliminationDiet.pdf
(317 KB, version 2020-07-20, references: [SIGHI.2].)

Please note that in most cases with histamine problems, this simplified diet is NOT sufficient and therefore NOT recommended. The simplified list is suitable only for those rare cases which are not susceptible to histamine liberators. Please try the strict elimination diet according to the following detailed list:

Strict elimination diet (recommended version)

If you follow a strict elimination diet, there are numerous additional foods and additives (E numbers) to avoid. This list includes also histamine liberators and therefore is suitable not only for histamine intolerance but also for mast cell activation disorders. References: [SIGHI.2].

Detailed list of >500 compatible and incompatible food ingredients and additives:
SIGHI food list EN, alphabetic, with categories, available in various sort orders and languages.

Despite its comprehensiveness, this food list does not claim to be complete or infallible. We are happy to receive your suggestions. The list also contains - as far as possible - information on the foods, which contain histamine or other biogenic amines, which liberate histamine or inhibit DAO. This affects the type of symptoms experienced and is important for the choice of medication!

The rating is for the basic food WITHOUT badly tolerated ingredients or additives. You have to carefully read the label, even for basic foods where one would not suspect any additives! Examples:

• Pure cream would be well tolerated. In most types of cream sold in grocery stores, however, you will discover badly tolerated additives such as E410 (locust bean gum, carob gum) in the fine print.
• Pure spirit vinegar (distilled colorless vinegar made of pure ethanol by oxydation; diluted acetic acid) would be well tolerated. Most spirit vinegars, however, also contain badly tolerated additives (preservatives and colorings) such as E202 (potassium sorbate).
• Pure marzipan paste (just sugar and almond) would be well tolerated, but most marzipan products also contain colourings, preservatives or surface treatment agents etc.
• Pure rooibos tea is well tolerated, but most types of tea labelled rooibos turn out to be mixtures of rooibos with other mostly not so well tolerated ingredients and flavors.
• Carrot juice and many fruit curds would generally be well tolerated, but they almost always contain concentrated lemon juice, which acts as a histamine liberator in people who are more sensitive.
• ...
• ...

If you do not manage to achieve and maintain a symptom-free condition with a strict elimination diet, it may be advisable to consider other problems in your diet (other badly tolerated ingredients or foods that are not fresh enough). If this is unlikely, you should consider other food intolerances or allergies, cross reactivity, metabolic or diet-related vitamin or nutrient deficiencies, mast cell disorders or other diseases. Also, we must not forget that with histaminosis and particularly with mast cell activity disease various environmental factors may drive up histamine levels.

Rice and potatoe diet

We recommend following the rice and potato diet when even the strict elimination diet does not achieve a satisfactory result. The potato/rice diet is easy to learn but difficult to follow. Only potatoes, rice, water, salt and sugar are allowed. No other foods, ingredients, spices or drinks are permitted. The rice and potato diet is not suitable as a permanent diet, but is only followed for 5-7 days. Subsequently you introduce a new type of food every two days and observe which groceries cause negative symptoms. The test and the interpretation of the results are performed jointly with a physician or a nutritional advisor. The goal is to work out a sustainable balanced diet with the help of a professional dietician.
If even potatoes are badly tolerated, you may have to get more information on salicylate sensitivity (salicylate intolerance).
Rice allergies occur very rarely in this part of the world, but they cannot be excluded.

Course of action

The three phases from diagnosis to the beginning of therapy

Phase 1: elimination diet

It is only possible in a symptom-free condition to find out how well you tolerate specific foods. This is why it is important to ingest only foods that are well tolerated (refer to food lists) until you master the diet well (at the beginning you tend to make a lot of mistakes) and do not suffer any symptoms! You have to follow the diet at least for two, but better four to six, weeks. If it works well, you only know one way of getting rid of the symptoms. But this is only the first part of diagnosis. Perhaps you badly tolerate something else, which is not linked to HIT and which is only by chance among the many things you have to avoid. Only phase 2 may confirm your suspicions:

Phase 2: Challenge test

You reintroduce badly tolerated foods from different food groups (meat products, dairy products, vegetables, fruits, additives, ...) one by one. In between, take breaks of 1-2 days until the symptoms have ceased. If you react to most of these foods, you can be pretty sure that you suffer from HIT. Phase 2 is thus not the beginning of a future unlimited diet but part of diagnosis. The point is to achieve clear results. The patient does not have to test every food on the list, but may conclude the phase once the result is clear enough.

The second important effect, which has to be achieved following phase 1 is that patients often do not consider the diet necessary because they feel well and healthy after the successful diet and do not have the same motivation they had when they were suffering severe symptoms. Moreover, the effort seems insurmountable. In order to be successful, you have to avoid so many foods, have to learn so many new things and maybe even have to isolate yourself socially for some time. You do not make those sacrifices just because your dietician tells you to. Thanks to the challenge tests with clearly badly tolerated foods your brain learns that there is no choice but to follow the diet.

Please note: Patients, who have had violent/anaphylactic reactions to histamine in the past, may have to proceed with caution.

Phase 3: Reintroduction of a varied diet

Once a patient is sure without any doubt that the hard to establish diagnosis applies, he or she is prepared to follow the arduous diet. Now, the patient may start to build up a diet that is as varied as possible but still sufficiently tolerable. From time to time, he or she may have to retry moderately tolerated foods (which often will have to be avoided as well in the long term). This is a learning process that may take many years.

The intensity of the symptoms depends on the dose. Foods that are "badly tolerated" may still be tolerable in small amounts. In order not to have to limit oneself too much, one should over time try out everything one does not want to go without one by one. In order to get reliable results, you should be without any symptoms at the time of the test (but not be taking any antihistamines) and subsequently only consume foods for two days where you are sure that you tolerate them well. This is important because in some cases symptoms may occur with a long delay. It is best to do the challenge tests a couple of times per type of food to exclude misinterpretations.

The diet must be followed permanently as long as the histamine intolerance pesists. In most cases this unfortunately means forever. Errors are usually punished with immediate effect by triggering histamine-related symptoms for a few hours.

What you have to know before you start a diet

Take on the challenge

Many people try to repress the condition in a first phase, when they are first confronted with the disease pattern of histamine intolerance and when they realise that HIT is the most likely explanation for their symptoms. You tell yourself: "No, I do not want to have this, it is too complicated, too cumbersome and too restricting." You wait for a spontaneous remission. In your own interest it is best to leave that repression phase behind as quickly as possible to prevent unnecessary suffering.

Arduous learning process

It is not surprising if you find it hard at the beginning to adjust to the dietary changes. They are difficult to get used to and they do restrict your quality of life, but it will get easier as you get more experience. You will over time discover new options, develop strategies, and in the search of tolerable foods you will expand your diet with up until now unknow dainties. Rejoice these new discoveries and revel in your regained wellbeing!

Exchange experience in support groups and discussion forums can support and accelerate this learning process.

The individual tolerance threshold is subject to large variation

The intensity and type of symptoms generally depend on the dose. By varying the amount (or the fresheness) of food, people affected by HIT may find out where their personal thresholds is, where badly tolerated food is still tolerable for them. You should try not to get too confused about the fact that tolerance thresholds may again vary depending on the current form of the day, which is influenced by many factors:

• What you eat and drink before, during and after a meal
• Stress (i.e. better tolerance during holidays compared to stressful times)
• Current vitamin and mineral levels
• Excessive physical strain
• Pollutants (smog, ozone, particulates), (passive) smoking
• Allergy sufferers: contact with allergens and cross reactions
• Amounts of sleep, sleep pattern, circadian rhythm (late nights, jetlag)
• Weather changes (particularly approaching cold fronts)
• Contaminated foods (heavy metals, pesticide residues, medication residues and other environmental pollutants?)
• Amalgam filling?
• etc.

This is aggravated by the fact that the histamine content in foods also varies widely. For that reason a certain meal may cause symptoms one time, while another time no symptoms occur.

Intolerance is not easy to identify

Some histamine liberators are hard to identify as culprits. It is possible that you are able eat some foods without symptoms for four days in a row and you are already happy that you tolerate them well. On the fifth day, however, it starts to dawn on you that negative symptoms have slowly but surely been creeping in, day by day. We do not just experience violent histamine episodes. Histamine liberators may build up subtly over days and very slowly cause completely different types of symptoms depending on the individual susceptibility. This may be expressed in an inexplicable feeling of sadness, an increase occurrence of infectious diseases, sleeping problems, a hangover feeling, crampy muscles, pulled muscles because of unusual silly movements, and backache; all symptoms, which the brain would not necessarily link to any foods that were ingested days earlier. This applies more to type HNMT, than to type DAO.

Foods, which do not contain histamine, but other biogenic amines in large amounts, are sometimes also difficult to identify as being the cause of an intolerance. Only few of the free biogenic amines themselves develop physiological effects (neurotransmitters, vasodilating effect), which are similar to the effect of histamine, or which have the effect of releasing histamine. Other amines do not directly trigger symptoms, but may indirectly amplify the consequences of other histamine sources (for example if you eat it in combination with foods already containing histamine). As a competing substrate to histamine they utilize the degrading enzyme to capacity, so that the degradation of histamine from other sources is delayed.

Slow decline of susceptibility

While some foods may at the beginning of the diet only be moderately tolerable because of an irritable colon, they may be better tolerated a few weeks later. That is why you should try to retest foods that were identified as badly tolerated a few months later.

Follow a balanced diet

There are well and badly tolerated items in every group of foods. This is why you often do not need to avoid an entire group, but you may still follow a balanced diet where you still have all the categories (meats, fish, dairy products, carbohydrates, vegetables, fruits) to choose from to supply the body with everything it needs. A dietary change does not mean that you have to restrict one of those categories too much!

In order to make sure that you do follow a balanced diet in the long run, it may be advisable to consult a dietician. This in particular applies to people who already suffer from other diet-restricting allergies or intolerances. The consultation with a nutricionist is generally reimbursed by the health insurance if it has been prescribed by a physician.

Supportive measures

The elimination diet may be supported by the intake of various food supplements and medication, so that the diet does not need to be followed by the book or that it may be temporarily dropped for special occasions (dinner invitations, travels), without any immediate occurrence of symptoms. This will allow you to transgress and enjoy food without any punishment from time to time. So, never say die! During the 4-6-week trial phase you should follow the diet as closely as possible and without any medication to make sure that it is the diet that is working and not just the drugs.

On page Therapie > Medikamente we describe the food supplements and medications as well as their administration.

Complementary information

You will find complementary information on page Therapie > Histaminpotential.

The page Therapie > Küchentipps contains tips, which may be critical for a successful therapy!

You should also consult the list of badly tolerated medication. You should, however, not discontinue prescribed medication without consulting your doctor!

Guided tour: Go to
therapy > histamine potential (German)

References and bibliography