This is how complex histamine intolerance is
I keep reading and hearing adventurous stories about the diagnosis of histaminosis or histamine intolerance. Apart from alternative medical nonsense such as hair analysis, spit analysis or laying on of hands and then measuring the body’s counterpressure, there are also conventional medical methods that are used even though they don’t work or are not recommended by the guidelines .
Although we have summarized how to diagnose a histamine intolerance in a detailed article, the correct way of diagnosis is not really getting around. This is also because many doctors are not aware of the complexity of histaminosis. So here is some more information and an attempt to explain histamine intolerance.
What is histamine intolerance or histaminosis?
Hippocrates is said to have described physical reactions such as hot flushes, discomfort, headaches and diarrhea after eating cheese1), but I have never been able to verify this source. I was also unable to verify the alleged report by John Fothergrill, who is said to have reported migraines after drinking wine and cheese in 17842). The fact is that in the mid-1960s biogenic amines were found to trigger certain symptoms associated with the consumption of long-ripened foods. More intensive research was carried out from the 1980s onwards and we have known since the 2000s: There is something there. But what?
That is difficult to say. Histamine is an important substance, we produce it ourselves and we absorb it through our food. And only this histamine absorbed through food is relevant for histamine intolerance! But not only that, other biogenic amines, which are broken down in the body via the same two degradation pathways, are also relevant. These degradation pathways are in the intestine via the DAO and in the blood via HNMT. It is therefore said that histamine intolerance is more of a “symptom complex that can only be attributed to histamine alone in individual cases “3).
The path of histamine – very simplified
- Histamine (and this now stands for all relevant biogenic amines) is therefore absorbed through food.
- It is then broken down in the intestine with the enzyme DAO. If this is missing or is only active to a limited extent, or if I take in too much histamine and my DAO is simply overwhelmed, as in the case of food poisoning, for example, I get symptoms. However, everything may also be in order here. The histamine is then absorbed and …
- … degraded in the blood by the enzyme HNMT. And here too, the HNMT may not be working properly or not be present enough. Then symptoms occur. The HNMT inhibits itself, i.e. it stops itself if too much of it is active. Problems can also occur here if, for example, there is too much histamine in the blood, which also circulates via routes other than food.
I want to show that: It’s really complicated! And unlike lactose intolerance, there is not just one enzyme, so if it doesn’t work properly, I have problems. No, there are two enzymes, several amines and many factors that can trigger or influence the problems. And usually not one of these variables is relevant, but several.
What does this have to do with the diagnosis?
Quite simply, we cannot measure one variable and draw meaningful conclusions. A symptom complex that depends on so many variables cannot be determined so easily by one or more blood values.
And I failed to mention in the previous section that the DAO or HNMT values in blood and urine do not provide any information about their activity or whether they are sufficiently present… so they are actually irrelevant for the diagnosis of histaminosis. I also didn’t mention the four different histamine receptors and a few other topics such as histamine-producing bacteria in the gut, necessary cofactors such as vitamin B6, histamine-releasing foods or the connection with allergies… histamine metabolism and the role of histamine in the body are simply extremely complex. That’s no understatement: it’s mega complex!
So, what is the correct diagnostic path?
The guideline here is quite clear 4). The anamnesis – i.e. the doctor-patient discussion and, if necessary, further specialist differential diagnostics – is followed by a nutrition and symptom diary. This is done without dieting for about 2 weeks. What is not recommended are DAO and histamine determinations in serum/plasma as well as stool analyses for histamine or bacterial colonization.
This is followed by a three-stage dietary change. In consultation with your doctor, you should continue to keep a symptom diary for at least 6 to 8 weeks. The three phases are the grace phase (2 weeks of a strict low-histamine diet), the test phase (slow testing of tolerated foods) and then the permanent diet. If there is an improvement after 6 to 8 weeks, a provocation test can be carried out under medical supervision. This serves to confirm the diagnosis of histaminosis. If there is no improvement, further diagnostic tests must be carried out. Here too, the symptom diary is an important source of ideas for the doctor.
The permanent diet for histamine intolerance
This last phase, the permanent diet for HIT, includes “individual dietary recommendations based on the individual histamine tolerance, taking into account exogenous influencing factors” 4) and should always be discussed with nutrition experts.
As you can see, it is complex and there is no simple method of diagnosing histaminosis. You simply have to get involved and can’t expect to get a diagnosis without having to do anything yourself, e.g. just through simple blood tests.
Steneberg A., 2007, Biogenic amines – nutrition for histamine intolerance; Environment & Health
Komericki P, Klein G, Hawranek T, Land R, Reider N, Stri- mitzer T, Kranzelbinder B, Aberer W. Orally administered di- amine oxidase (DAO) in patients with suspected histamine intolerance. Allergology 2008;31:190
Guideline on the procedure for suspected intolerance to orally ingested histamine, 2017; Allergo J Int 2017; 26: 72-9