Detecting and Treating Histamine Intolerance (HIT).

Histamine is closely related to allergies and immune responses. Certainly, histamine’s involvement in common allergies is the main reason why antihistamines were developed. However, the gastrointestinal environment and food consumption are the most common histamine levels influencers in our bodies. High quantities of histamine cause non-specific, non-allergic GI complaints. These consequences are associated with increased consumption of histamine-containing foods or a diamine oxidase (DAO) dysfunctional enzymatic action. The identification of histamine intolerance (HIT) is challenging. The differential diagnosis is tricky without a settled normal range of DAO and the variety of overlapping GI disturbances. Providing information on how to determine and detect HIT is critical for the proper intervention of this condition.

What is histamine?

Intestinal bacterial produce histamine, a biogenic amine, along with putrescine, cadaverine, and tyramine. Furthermore, the amino acid histidine conversion results in histamine production, mainly through a decarboxylation process. 

Certain foods and their elaboration process contribute to the amount of histamine in our bodies:

• Manufacturing process.
• Cleanliness of materials.
• Microbial composition.
• Fermentation.

Consequently, histamine concentration is an essential part of food adequacy. This is why the histamine concentration of only 400 mg/kg and 200 mg/kg are allowed in seafood and fresh fish, respectively. Nevertheless, a higher amount of histamine in food may imply a higher risk of scombroid poisoning. In turn, scombroid poisoning associates with the consumption of decaying seafood or fish, where histamine concentration elevates in the presence of contaminating bacteria.

Histamine Intolerance (HIT)

Similar to lactose intolerance, histamine intolerance (HIT) is caused by an enzymatic deficiency of gastric enzyme diamine oxidase (DAO), whereas lactose intolerance is due to lactase deficiency.

DAO ‘s genetic expression is mainly in the small intestine, ascending colon, placenta, and kidneys. Mature intestinal enterocytes produce this enzyme, and during digestion, they release it to the mucosa and blood circulation. DAO has the enzymatic activity of degrading microbiota-generated histamine.

Determination of Histamine Intolerance:

The diagnosis of histamine intolerance is difficult and up-to-date there is no current questionnaire to support its detection. However, for those patients with non-allergenic reactions, this list of gastrointestinal, dermatologic, cardiovascular, and respiratory symptoms might be helpful.

Gastrointestinal symptoms:

The principal issue in detecting HIT is the overlapping gastrointestinal symptoms shared with other conditions. The following gastrointestinal problems should be addressed as part of the HIT assessment. 

• Abdominal pain.
• Intestinal bloating.
• Bloating.
• Diarrhea.
• Constipation.
• Nausea.
• Belching.
• Vomiting.
• Postprandial fulness.
• Menstrual cramps.

Skin conditions associated with HIT:

Skin appearance and severity of the symptoms play a principal role in differentiating HIT from other conditions, such as allergies and autoimmune disorders.

• Pruritus.
• Eczema.
• Reddened skin.
• Swollen, reddened eyelids.

Cardiorespiratory issues linked to HIT:

• Headache.
• Dizziness.
• Hypotonia.
• Palpitations.
• Collapse.
• Rhinorrhea or nasal congestion and sneezing.
• Asthma.

Differential Diagnosis:

As seen on the above list, HIT symptoms may invariably overlap with other conditions or are often overseen by the patients. Besides this, there are 50 known genetic variations for the DAO enzyme. This may partially explain why this condition has many faces and varying symptomatology. In addition, the food’s freshness and dietary preferences play a principal role in this disease. 

On the other hand, the determination of serum DAO (<10U/mL) can serve as a reasonable cut-off point to contribute to HIT’s diagnosis. However, there is no current consensus on how serum DAO levels correlate with DAO’s GI activity. 

HIT Treatment:

Similar to what happens after an elimination diet, the prescription of a low-histamine diet should be part of the treatment protocol. Also, this protocol, in combination with DAO supplementation, may ensure the patient’s wellbeing and improve their quality of life.

In my experience as a nutritionist, I have dealt with many forms of gastrointestinal issues. For me, it is crucial to listen to the patient’s symptoms. But I have to be very honest, once that symptom list starts to get long, I get fearful about their quality of life, and the diagnosis begins to get blurry. Detecting HIT calls for a clinical eye and lots of patience on the clinician’s behalf. A thorough dietary dairy, DAO testing, symptom assessment, and feeding habits recall are the cornerstones of the nutritional treatment. – Ana Paola Rodríguez Arciniega, MS.

 References:

Schnedl, Wolfgang J, and Dietmar Enko. “Histamine Intolerance Originates in the Gut.” Nutrients vol. 13,4 1262. 12 Apr. 2021, doi:10.3390/nu13041262

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