CASE STUDY
Food allergies
Exercise-induced anaphylaxis
Histamine sensitivity
History
• It is important to obtain a clear history to
determine which symptoms are related to
allergy
• Clients often believe that all their
symptoms can be “cured” with the right
diet
• Determining which are related to food
allergies and intolerances and which are
not is often a matter of experience
2
Early Life and Allergies
• As a child I never experienced allergies
but I did have very painful periods where
vomiting, diarrhea, and painful cramps
were standard
• Two important points here:
– No history of childhood allergies; neither food
nor environmental (air-borne) allergy
– Unlikely that painful periods were related to
allergies or food intolerances
3
First Experience of Allergy
Symptoms
• Fast forward to age 30, I developed hives going
for walks and a few years later I had a couple of
allergy skin tests and the only ones I tested
positive for were wheat, barley and dust mites. I
was able to eat wheat with no problems but if I
ate it and exercised, anaphylaxis
• Two points to clarify here:
– Were the hives identified as exercise-related?
– Was anaphylaxis actually diagnosed by a doctor? Or
was this something the patient determined as a result
of reading?
4
Value of Information
• Alert to the possibility of food-dependent
exercise-induced anaphylaxis (FDEIA) in
response to wheat
• Allergy to barley
– Dietary management: gluten-free diet is the easiest
way to eliminate both wheat and barley as there are
now many gluten-free foods readily available in the
market-place
• Dust mite allergy; not food-related but indicates
atopy
5
Avoidance of Gluten:
a common practice
• Eventually, I started getting
gastrointestinal symptoms so got off of
gluten totally
• In this case avoiding gluten was a good
strategy because of established allergy to
wheat and barley
• However, this underlines a very common
belief, that all GI problems are caused by
a sensitivity or allergy to gluten
6
Another common belief
• I thought my problems were solved until a month later I
started developing neurological symptoms like weak,
tingly or numb arms, pain up and down my spine and
head pain. Then I got migraines off and on. I finally found
that nightshade veggies were my problem through a food
elimination diet, so I got off those and my symptoms got
better
• There is a common belief that foods from plants in the
nightshade family (Solanaceae) are the cause of some
neurological symptoms. The culprit constituents are
considered to be alkaloids
• There is no firm research evidence for the impact of the
alkaloids in nightshade foods on the nervous system or
joints
7
Nightshade Foods and Histamine
• Nightshade foods include:
– Potatoes
– Tomatoes
– Capsicum
• Sweet peppers
• Paprika
• Cayenne
– Eggplant
• These foods include those associated with
histamine excess
• The history of hives and the new symptoms
reported are likely due to histamine intolerance
• Removal of these foods would achieve symptom
remission if histamine intolerance is the cause
8
Asthma and Respiratory Tract
Symptoms
•
I was also getting asthma symptoms and sinus pressure
due to what I ascribed to dust allergies as I was getting a
lot of these symptoms at night but sometimes during the
day too. The asthma related symptoms I believe were
caused by memory foam. A lot of my health problems
started with the addition of a memory foam pillow and
mattress topper. After finding a blog on memory foam
allergies, I discovered that this may be causing some of
my problems. Within 3 days of taking all memory foam
out of the house, my asthma got better. I still have
sensitive lungs to strong odours, chemicals and during
windy or stormy days I get shortness of breath but it is
not constant
9
Environment or Foods?
• The asthma may be triggered or
exacerbated by the foam, or by dust mites,
to which she tested positive in earlier
allergy tests
• From this report it is safe to assume that
the asthma symptoms are related to
inhalant allergen exposure and not to any
dietary factor
10
Influence of Hormonal Changes
• Fast forward 2 years (I am almost 48 yrs old
now) and then my weak arms returned. I was
getting hot flashes, headaches, fatigue, itchy
skin with the odd hive especially around my face
and neck area, asthma, aches in joints,
interstitial cystitis, acid reflux, pressure and
fullness in ears and head, runny nose, eyes
blurry, achy and watery, insomnia, etc.
• I do believe I am in menopause or at least close
but I had an endometrial ablation in 2007 so
have had no periods to track for years.
11
Influence of Changes in Hormone
Levels
• The hormone changes in menopause are
often associated with dysregulation of
histamine
• The symptoms previously reported and
suspected to be due to histamine
intolerance (hives; neurological
complaints) will reappear during hormonal
changes
12
Internet Research
• I began researching again online and came
across your article on Histamine intolerance. I
have tried to start a low histamine diet but all the
articles and websites on histamine intolerance
were conflicting in what foods to eat and
eliminate. I am using a couple of apps to help
keep a diary of symptoms and tolerated foods
and another app which helps identify those
foods that are high in histamine though I am not
sure if its food list is correct.
13
Conflicting Information
• Misconceptions:
– Several lists include “amines”. This is a
meaningless term as each “amine” has a
different structure and effect, for example:
– Tyramine
– Phenylethylamine
– Cadaverine
– Putrescine
– Octopamine
14
Omissions
• Most lists do not include ingredients that
release histamine, including:
– Tartrazine
– Benzoates
– Sulphites
• To reduce histamine from extrinsic sources
these must also be avoided
15
Misconceptions
• Many lists exclude foods that are
commonly considered to have adverse
effects, especially:
– Wheat
– Gluten grains
– Milk
• These foods do not contain or release
histamine unless fermented
16
Occasional Symptoms
• Although most of my symptoms have been acid reflux,
asthma, skin related itch and tingling, insomnia and
headaches, I did get a different reaction that was closer
to anaphylaxis when I ate week and a half old kale,
almonds and Greek yogurt. My throat tightened, the back
of my neck got tight and felt pressure, my skin got hot
and tingly but no hives appeared except on my very hot,
itchy ears. It scared me so I took my Benadryl, got out
my EpiPen and waited but I guess the Benadryl worked
as it did not continue and I just had a long nap after. I
have eliminated nuts as I think it could have been the
almonds, though I think I can tolerate some peanut
butter as I had some marshmallow squares at Christmas
that didn't seem to bother me.
17
Explanation
• In this case, the term “week-old” is
significant.
• Both histamine and tyramine will be
produced by the microbial activity that
would result from week-old vegetables and
yogurt
• The patient tries to blame the foods that
she sees as possible culprits (nuts;
peanuts); however, she is wrong
18
Fears
• Further, I am scared that with all this
inflammation from the high histamine I will
end up with a serious illness like cancer or
something
• There is absolutely no evidence of a
connection between histamine, even at
high levels, and cancer or other acute
illnesses
19
Medications
• My doctor has no clue about this and
basically told me to use antihistamines
• There is very little understanding about
histamine sensitivity in North America
• Most of the research has been carried out
in Europe (Germany and Austria) and is
not part of any regular clinical practice in
the USA or Canada
20
Antihistamines and Histaminosis
• In most cases, antihistamines are
contraindicated in the control of histamine
intolerance or sensitivity, except as a
“rescue remedy” during acute episodes
• Antihistamines as a prophylactic measure
can have a rebound effect and increase
the patient’s histamine levels
21
Non-histamine Related Medications
• He even gave me samples of Singulair to try but
they made me feel ill and did not help
• Singulaire (Montelukast) is a leukotriene
receptor antagonist used in the control of
asthma.
• It has no antihistamine activity
• It would have been prescribed to help control the
patient’s asthma, not any of the other symptoms
she describes
22
Histamine and Diet
• I sought a dietician and she was just as clueless
as she knew little about histamine intolerance
and I ended up advising her more than she did
me
• This is a common scenario in which the
patient/client has carried out extensive research
on their condition
• This can have both positive and negative
outcomes
• It is often very difficult to counsel such clients
• The role of the dietitian here is to ensure that the
client obtains complete balanced nutrition and
avoids any risk of nutritional deficiency
23
Bottom Line
• I am feeling very alone as I have no clue what to
eat and what not to and I am worried that my
nutrition will suffer if I am too severe in my food
restrictions.
• She is expressing confusion as a result of her
own research and the perceived lack of support
by her health care providers
• The dietitian’s role here is:
– Reassurance
– Acknowledgement of the expressed concerns
– Development of a meal plan to support the client’s
beliefs while providing complete balanced nutrition
24
Present Diet
•
•
•
•
•
•
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•
•
•
•
•
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I eat nothing but chicken and turkey and some lamb or eggs
Good sources of protein
My sides are brown rice or quinoa or yams
Good choices of grains and starch
Veggies are broccoli, carrots, cauliflower, snap peas, corn
Good choices
Fruits are apples, pears, grapes or banana
Good choices
I drink water ad nauseum
Good. But don’t overdo it!
I eat porridge every day
Good
The only snack I can have is hot buttered popcorn and Kozy shack's
gluten free rice pudding
• With these I don't get a huge amount of symptoms
• Great!
• Surprisingly, this regimen provides a good range of nutrients
and even when followed for the long term would pose no great25
nutritional risk or concern
Now we enter another dimension!
• I love desserts but cannot find too much to fill my
craving. I tried making carob chip cookies but my
histamine symptoms got worse and I discovered sugar
triggers adrenalin release to an already overworked
adrenal gland
• Now here we get into the realm of unproven hypothesis
and possibly alternative medical practice and
misconceptions
• Dietitian’s role is to try to come up with some dessert
recipes
• Don’t get into debates about sugar and adrenal function
– it will only lead to confusion and possible distress!
26
Frustration!
• I get depressed at lunch and supper time
because I am so limited in what I can make and I
am in tears as I just don't know what to make. All
the familiar foods that I was used to using were
now forbidden. I downloaded some e-cookbooks
but the foods are not what I am used to making,
take a long time to prepare and some of the
fresh ingredients are not available in Canada. I
have to make my family something different
everyday as my diet is so bland and limited, I will
not condemn them to my misery. I feel now that I
am eating to live not for any enjoyment.
27
Response
• This is a common theme in food allergy and intolerance
practice:
– I want to eat “normal food” (whatever their conception of
normal may be)
• At some point the patient/client has to come to terms
with the fact that what they previously considered as
“normal” only resulted in physical and sometimes
neurological distress
• The new regimen, once their sensitivities have been
identified accurately, will allow them to live symptom-free
• Their choice is between eating ad lib and remaining
healthy
• The dietitian’s role here is counselling: “quality of life”
versus dietary satisfaction
• In extreme cases (anaphylaxis) the choice may between
life and death!
28
Panic!
• Eating out is a nightmare because all the foods that I
used to order that were free from my initial allergies and
intolerances are now forbidden too. The thought of going
out to dinner or to someone else's house for dinner is
depressing as there are so many things to know about
their food so I find I am feeling house bound as going out
requires preparation and long explanations should I have
to eat out. Travelling I feel is not available to me as then I
would have to worry about what to eat, is the weather
too hot or cold, what if I go anaphylactic at Disney World
due to heat and eating wrong foods, etc. I do carry an
EpiPen.
29
Reassurance
• The dietitian’s role here is:
• Reassurance: anaphylaxis is most unlikely
– The Epipen is a good safeguard
– Make sure she understands how to use it
• Reinforce planning
• Educate about food labels
• Provide guidance for meals in restaurants and
away from home:
– Do not hesitate to ask about ingredients
– Most restaurants provide lists of ingredients; if not,
avoid that restaurant
• Emphasis:
– Careful not fearful
30
Fearful!
• I am also scared to exercise so my histamine
soars but I need to exercise as I am getting older
and again may develop illness due to inactivity.
Every time I have done a 20 minute brisk to
moderate pace of walking in front of my TV I feel
like I am getting the flu for the next couple of
days to weeks. I run a day home and I am
worried about taking walks in the summer
should it be too hot and I ate the wrong things
and I go anaphylactic.
31
Reassurance
• Moderate exercise
• Wait 2-3 hours after eating before
exercising
• Avoid known allergens
• Avoid histamine-associated foods
• Balanced diet avoiding reaction triggers
32
Management
• I would appreciate any help you could give
me because right now I am rather down
and depressed about the continued
downward spiral of my health these last 5
years especially
33
Plan
• Avoidance of allergens:
– Wheat
– Barley
• Gluten-restricted diet
• Histamine-restricted diet
• Meal plans for home and travel to provide
complete balanced nutrition
• Education regarding sources of reaction triggers
– Food labels
• Follow-up to monitor:
– Symptoms
– Weight
– Nutrient intake
34
Follow-up
• The dietitian needs to be somewhat of a
psychologist: emphasise the positive and try to
avoid the client’s tendency to see herself as a
victim
• In dose-related sensitivities such as histamine
intolerance there may be ways to liberalize the
diet and allow some of the client’s favourite
foods in small quantities on occasions once the
symptoms are under control
• Exert caution in introducing wheat and barley
because of the risk of exercise-induced
anaphylaxis
35