CASE STUDY

Food allergies

Exercise-induced anaphylaxis

Histamine sensitivity

2

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

3

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

4

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?

5

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

6

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

7

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

8

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

9

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

10

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

11

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.

12

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

13

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.

14

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

15

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

16

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

17

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.

18

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

19

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

20

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

21

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

22

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

23

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

24

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

25

Present Diet• 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 great nutritional risk or concern

26

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!

27

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.

28

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!

29

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.

30

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

31

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.

32

Reassurance

• Moderate exercise

• Wait 2-3 hours after eating before exercising

• Avoid known allergens

• Avoid histamine-associated foods

• Balanced diet avoiding reaction triggers

33

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

34

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

35

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