Master the Low Histamine Diet: Ultimate Guide to Relief and Delicious Meals

Many people are familiar with antihistamines, over-the-counter medications like Benadryl, which can provide relief from allergy symptoms such as sneezing and a runny nose. However, the counterpart of antihistamines, histamine, may be less well-known. Histamine is a chemical naturally found in the body and in foods. An overabundance of histamine can lead to a condition known as histamine intolerance. This article explores the low histamine diet, a strategy used to manage histamine intolerance by reducing the intake of histamine-rich foods.

Understanding Histamine and Its Role

Histamine is a chemical naturally present in all of the body’s cells and is an important component of both the immune and nervous systems. Histamine helps the body eliminate substances that shouldn’t be there, such as allergens. It is a specialized neurotransmitter highly concentrated in immune system cells. When the immune system perceives a threat, such as pollen, it triggers an inflammatory response, and mast cells release histamine. Histamine is also involved in key functions such as sleep cycles and cognitive processes.

In addition to the histamine that the body makes, histamine is also naturally present (or can develop) in certain foods. Histamine becomes a problem when the total amount of histamine circulating in the body exceeds the body’s ability to break it down. Diamine oxidase (DAO) is the enzyme responsible for breaking down histamine and clearing it from the body. Unfortunately, the DAO enzyme can be blocked by certain medications, such as antidepressants, and foods, such as black tea and alcohol, or a person could be born with a DAO enzyme deficiency.

What is Histamine Intolerance?

Histamine intolerance is not a food allergy, but rather a sign that you have too much of the chemical in your body. It arises from the failure of the diamine oxidase (DAO) enzyme to degrade dietary histamine at the intestinal level. DAO deficit results in an increase in systemic histamine concentrations and the subsequent onset of symptoms. This enzyme deficiency may have a genetic or pathological etiology or may be secondary to certain inflammatory bowel diseases. Some widely used pharmacologic drugs have also been described as potential DAO inhibitors, although in a punctual and reversible manner.

It is currently a clinical diagnosis, but there is no agreed-upon diagnostic test at this time. However, it is possible to measure DAO activity and histamine levels in the blood, which could help a doctor determine whether histamine intolerance is present.

Histamine intolerance may be something you’re either born with or develop over time. Diet-related causes include overgrowth of bacteria in the GI tract, which may result in too much histamine in the bloodstream, other gastrointestinal disorders, such as Crohn’s disease or ulcerative colitis, that cause fluctuating histamine levels, and intake of histamine-rich foods, such as smoked meats and fermented items, which can raise your histamine levels overall.

Symptoms of Histamine Intolerance

Plasma histamine accumulation can provoke a wide number of nonspecific gastrointestinal and extraintestinal clinical manifestations, such as dermatological, respiratory, neurological, and hemodynamic complaints. The most frequent and severe symptoms include abdominal distension, diarrhea, postprandial fullness, abdominal pain, and constipation, followed by headaches, dizziness, and palpitations.

Symptoms of histamine intolerance are wide-ranging and may include hives, digestive issues, vomiting, headaches, nasal congestion, stuffiness, abnormal menstrual cycles, tiredness and fatigue, abdominal cramping, heart palpitations, anxiety, and difficulty regulating body temperature and blood pressure. Some symptoms of histamine intolerance are severe and warrant seeking immediate medical attention.

Many conditions can cause the above symptoms, so just because you have one or more of these symptoms does not mean you have a histamine intolerance. Additionally, sometimes histamine intolerance is associated with certain conditions, such as Crohn’s disease and ulcerative colitis, two types of inflammatory bowel disease (IBD). Celiac disease is also associated with histamine intolerance.

Diagnosis and Testing

Clinicians do not have a tried-and-true way of diagnosing histamine intolerance, but a few methods can help determine whether the issue affects you. One is an elimination diet. The low histamine diet helps you eliminate high histamine foods to see if your symptoms resolve. Then you slowly reintroduce these foods, one at a time, to see if symptoms return after eating a specific food.

If you have symptoms of allergies or histamine intolerance, talk to your doctor. They might recommend keeping a food diary. This involves writing down the foods you eat and symptoms you have each day. A food diary can help you find patterns and figure out if a certain food (or combination of foods) is causing your symptoms.

Your doctor also might suggest avoiding all foods high in histamines for a few weeks. If this helps you feel better, you may have a histamine intolerance. To find out if there’s a particular food that triggers your histamine intolerance, slowly add foods back into your diet, one at a time. If you start getting symptoms again, the recently added food might be a trigger.

They may also prescribe allergy testing, which can help show whether your symptoms are being caused by allergies. You might get a skin prick test, where the doctor pricks your skin with tiny drops of allergens to see if they cause a reaction, or you might get a blood test. Blood testing can show whether you have high levels of histamine, low levels of DAO, or other irregularities. During a histamine skin prick test, a doctor pricks your skin with a tiny drop of histamine. This will probably cause a reaction, but if the reaction doesn’t go away after 50 minutes, your body might have a hard time breaking down histamine. They may also give you a histamine pill to see how your body reacts. During a colonoscopy, your doctor can check histamine and DAO levels in your colon. They can also look for signs of other conditions that might be causing your symptoms.

The Low Histamine Diet: Principles and Guidelines

A low-histamine diet is currently the most advised strategy to prevent the symptomatology of histamine intolerance. Conceptually, these diets should be founded on the exclusion of histamine-containing foods. It’s an eating plan that focuses on minimizing the total amount of histamine you consume daily by eliminating particular foods that contain higher levels of histamine. While it’s impossible to avoid histamine in foods altogether, opting for those with less of the chemical can help decrease overall histamine intake. And this, in turn, can be used to prevent histamine overload - and reduce the risk of developing a histamine intolerance - for those who can’t break it down fast enough.

In addition to opting for low-histamine foods, the diet also involves eliminating foods and drinks that block the action of the DAO enzyme. You can think of the DAO enzyme as similar to lactase that helps people digest lactose, the sugar in milk.

Duration and Purpose

The low-histamine diet isn’t meant to be followed long-term, and you should reintroduce foods after a specified elimination period under the guidance of a medical practitioner (usually 4-6 weeks). It’s important to note that the low-histamine diet isn’t to induce weight loss. It’s typically recommended for someone experiencing symptoms related to histamine excess. The challenge is that these symptoms can be caused by many other conditions. It’s crucial to determine why the symptoms are happening because the best treatment may not always be a low-histamine diet. For example, if you have a true food allergy, testing may reveal that certain foods may need to be removed from your diet vs. eliminating the entire list of histamine-containing foods. The same could be said for medications (such as some antidepressants and antibiotics) that could be at fault, and switching up your meds could be the better solution. What’s more, certain symptoms (e.g. nausea, vomiting) might actually be related to conditions such as celiac or inflammatory bowel disease, and, in that case, treatment may also be completely different.

And while you can try an elimination diet (removing foods high in histamine content and monitoring symptoms) to try to determine the cause of your symptoms, you should not try to self-diagnose histamine intolerance and always see a doctor. Keep in mind, however, that histamine intolerance is a relatively newly discovered condition, so the low-histamine diet has not been well studied in all conditions.

Challenges and Controversies

There’s some controversy surrounding what foods to eat on a low-histamine diet because it’s difficult to accurately measure the histamine content of foods. Specifically, research shows this is because the histamine level in edibles varies depending on multiple factors, including pH, salt levels, and protein content, among others. Additionally, many factors affect the histamine content beyond the food itself, including variables such as temperature, age of food, and method of processing or manufacturing. For example, the histamine content of food rises as it ages.

One of these is the lack of consensus on the histamine level below which a food is said to be considered low in histamine. Thus, variable histamine levels in food ranging between 5-50 mg/kg have been pointed out as potential thresholds, while other authors are much more demanding and consider foods with low histamine concentrations to be those that contain amounts below 1 mg/kg.

Overall, providing dietary recommendations and guidelines in the frame of a low-histamine diet is difficult for healthcare professionals. In fact, disparity is found in the list of excluded foods reported by the different available low-histamine diets.

Foods to Avoid on a Low-Histamine Diet

Researchers have yet to agree upon a unified low histamine diet. However, they seem to agree on a general list of foods to avoid when first beginning a low histamine diet. Conceptually, low-histamine diets should be based on the exclusion of histamine-containing foods. Histamine in foods is mainly formed by the bacterial decarboxylation of its precursor amino acid, histidine.

When following a low-histamine diet, it’s also important to consider the age of food, as histamine content rises as edibles get older.

Here’s a list of foods that are generally considered high in histamine:

Alcoholic beverages: Beer and wine, especially red wine, have high levels of histamine. Because of this, some cases of alcohol intolerance are caused by histamine intolerance. Migraines are one of the main symptoms associated with a reaction to alcohol due to histamine.
Canned and semi-preserved fish: Frozen, smoked, and canned seafood, as well as spoiled fish, can have high levels of histamine. Pay particular attention to mackerel, sardines, tuna, herring, and shellfish.
Cured meat: Opt for fresh meat over packaged, smoked, or otherwise preserved products. This means avoiding sausage, deli meats, and bacon.
Dry-fermented sausages
Cheese: Aged, smoked, unpasteurized, pasteurized, and blue cheeses are loaded with histamine. This is because the cheese-making process, particularly ripening, raises histamine levels. One study found that the age of cheese and the temperature at which cheese is stored can affect histamine levels. The histamine content found in cheeses stored at 22 C was higher than the histamine content found in cheese stored at 4 C. Fermented dairy products, such as cheese (especially aged), yogurt, sour cream, buttermilk, and kefir, should be avoided.
High-histamine fruits: Although many fruits are not high in histamine, they can trigger the release of histamine. Some may contain histamine-like substances that can aggravate symptoms. Many health care professionals recommend limiting certain fruits and juices as part of a low-histamine diet. Consider avoiding bananas, pineapple, papaya, citrus fruits (such as lemons, limes, and oranges), strawberries, and cherries.
High-histamine vegetables: These vegetables are high in histamine: tomatoes, eggplant, and spinach. In addition, mushrooms and soybeans may contain histamine-like substances that can trigger symptoms.
Sauces and condiments: These ingredients can raise your histamine levels: sauerkraut, soy sauce, vinegar, chili powder, cinnamon, and cloves. Tomato ketchup should also be avoided.
Legumes: Legumes are a broad category of beans, lentils, and peanuts. The following legumes don’t have a lot of histamine but have high levels of histamine-like chemicals: chickpeas, lentils, peas, peanuts, and soybeans.
Fermented foods: The level of histamine in fermented foods (such as kimchi and kefir) can vary based on preparation techniques and the length of aging. Sauerkraut, in particular, has been shown to contain a high concentration of histamine compared with other common foods. Fermented vegetables, such as sauerkraut and kimchi, pickles or pickled veggies, kombucha, fermented soy products such as tempeh, miso, soy sauce, and natto, and fermented grains, such as sourdough bread, should be avoided.
Other foods: Other foods that could raise your histamine levels are tea, licorice, chocolate, pork, egg whites, and additives (such as colorings and preservatives).

Foods with Other Amines

Foods that contain chemicals called amines that are similar to histamine can also compete for DAO. This means that if someone eats lots of these foods, histamine will not break down as quickly and may cause symptoms. Foods that contain other amines include citrus fruits, mushrooms, soybeans, bananas, and nuts.

Medications

Certain medications may also have a link with histamine intolerance, especially if they interfere with DAO activity. Some medications can raise your histamine levels, including antidepressants, diuretics, blood pressure medications, opioids, muscle relaxants, anti-inflammatory medications, and antibiotics. Ask your doctor whether any of your medications could contribute to high histamine levels. They may be able to help you find an alternative medication. They also could prescribe antihistamines, DAO supplements, or medications that prevent the release of histamine. Don’t change or stop taking medications without talking to your doctor.

Low-Histamine Food Choices

Elimination diets tend to focus on what to avoid, but when embarking on a low histamine diet, knowing what you can eat is also helpful. There are certain foods that are generally considered to be low in histamine, but again, any diet is highly individual.

When eating a low-histamine diet, it is important to make sure you’re still eating a variety of fresh foods and taking in necessary nutrients. The following foods are low in histamine. If you’re limiting the consumption of histamine, try these and other low-histamine alternatives:

Fresh meat and chicken
Eggs are safe in small amounts; the whites may release histamine.
Some fish, including trout and hake
Fresh fruits and fruit juices (but not citrus)
Fresh vegetables (but not tomato, eggplant, or spinach)
Herbal tea
Grains and grain products, such as rice and bread
Honey
Fresh pasteurized milk and milk products
Milk substitutes, such as goat milk and sheep milk
Cooking oils

Sample Meal Ideas

Here are sample food ideas for breakfast, lunch, dinner, and snacks on a low-histamine diet:

Breakfast: 1/2 cup oats made with 1/2-3/4 cup oat or coconut milk, 1 teaspoon maple syrup and 1/2 cup low-histamine fruit (e.g. apple, melon, pear). Oatmeal made with water or coconut milk, puffed rice with coconut milk, apple, melon, and pear fruit salad with chopped pistachios, or a smoothie made with mango, coconut milk, chia seeds, and kale.
Lunch: Quinoa salad made with 1 cup quinoa, 1 cup diced zucchini, 1/4 cup cilantro, 1/4 cup green onions, 3 ounce chicken seasoned with salt and pepper, 1/4 cup grated carrots and 2 tablespoon fresh mint; toss with dressing of 3 tablespoon olive oil, 1-3 teaspoon honey, 1/8 teaspoon vitamin C crystals (which can add tartness in place of lemon or lime, as citrus can be problematic for those with histamine intolerance). Chicken and kale salad with chopped grapes, chicken, lettuce, and grated carrot sandwich, cottage cheese and cucumber on toast, or quinoa and herb salad.
Dinner: Low histamine fish, such as trout or cod, freshly caught and served with zucchini and roasted carrots. Chicken with new potatoes, broccoli, and green beans. Pasta with olive oil, garlic, herbs, and chicken or borlotti beans. Homemade turkey burger with sweet potato wedges.
Snacks: Blueberries, pistachios, carrot sticks, cottage cheese, grapes, celery sticks, or apple slices and natural peanut butter.

Practical Tips for Following a Low-Histamine Diet

Here are some strategies for following a low-histamine diet:

Keep a food diary: Start keeping a food and symptom diary when you start your low histamine diet and as you slowly add foods back in. Write down the date, time, and contents of each meal, snack, and beverage (aside from water) and note if the meal produces any symptoms. Include the type of symptom, its severity, and the time. This can help you track what foods trigger your symptoms.
Talk to a registered dietician: Everyone has different histamine tolerances, health needs, and food preferences. A registered dietician can help find a plan that’s right for you. They’ll make sure you’re getting all the vitamins and minerals you need while staying away from foods that trigger you. This is especially important if you have other health conditions that affect your diet, such as diabetes. A GI Registered Dietitian may even recommend a reduction in high histamine foods instead of a strict low histamine diet.
Choose fresh, whole foods: Any type of processing, especially fermentation and curing, dramatically raises a food’s histamine levels. This is partly because as food gets processed or ages, histamine-making bacteria start to grow. Avoid anything that’s canned, smoked, or dried. Instead, stick with fresh foods (except for any that might trigger you, such as citrus or tomato).
Store your food safely: As foods age, they become higher in histamine. You can slow down this process by storing foods in your refrigerator or freezer. When it comes to storing cheese, the lower the temperature, the better.
Get cooking: This gives you more control over the ingredients in your food and how they are prepared and stored. Plus, cooking methods can impact histamine levels. For example, braising and steaming produce less histamine than grilling.
Take supplements: Some research suggests that copper, vitamin B6, and vitamin C can help lower histamine levels. Talk to your doctor before changing your diet or starting supplements. They can help you choose foods, strategies, and supplements that won’t interfere with other health conditions or medications.
Plan meals in advance:
Buy fresh food, shopping more often if necessary:
Eat foods as soon as possible after purchase:
Ask restaurants about their ingredients when eating out:
Keep a food journal to record symptoms and triggers:

The Importance of Freshness

Freshness impacts the amount of histamine in food. It is a good idea to learn how different methods of production and storage impact histamine levels in food. Foods’ histamine content increases as they age or spoil. Some research shows that freezing foods lessens histamine generation in foods.

Considerations and Potential Risks

A low-histamine diet might not be a good idea for people with a history of an eating disorder. The main risk of following a low-histamine diet is that it may overlook other potential causes of your symptoms, as there are no definitive tests to diagnose histamine intolerance (HIT). By assuming HIT is the issue, you may miss other underlying problems. It’s crucial to explore other possible causes before jumping to a HIT diagnosis and starting a low-histamine diet. The low-histamine diet can also be quite restrictive, which may make it difficult to follow, especially if you have other dietary restrictions (e.g., FODMAP or gluten intolerance). When you need to manage multiple dietary restrictions, ensuring proper nutrition can become a challenge.

Low-histamine diets can be extremely restrictive and can lead to malnutrition. Histamine intolerance is poorly understood and difficult to diagnose. There’s no evidence that a low-histamine diet will improve quality of life in the long term if you don’t have a true diagnosis. Nutrient deficiencies can be harmful at any age, but this diet is especially dangerous for children. If you suspect your child has food allergies or sensitivities, talk to your pediatrician about an alternative treatment. If you experience dizziness, headaches, or any other complications, you should stop this diet immediately and consult a doctor.

Reintroducing Foods

After a period of avoiding certain foods on a low histamine diet, you’ll carefully add foods in, one at a time, with the guidance of your clinician. After you eliminate or reduce histamine in your diet for 2 to 4 weeks, you can begin slowly introducing histamine-rich foods back into your meal plan, one at a time. Talk to your doctor or nutritionist about how best to reintroduce these foods.

Start keeping a food and symptom diary when you start your low histamine diet and as you slowly add foods back in. Write down the date, time, and contents of each meal, snack, and beverage (aside from water) and note if the meal produces any symptoms. Include the type of symptom, its severity, and the time.

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