Histamine Intolerance

Histamine is a chemical which occurs naturally in certain foods. This is also one of the chemicals that is released in the body as part of an allergic reaction, causing the typical itching, sneezing, wheezing and swelling allergy symptoms.

We all have an enzyme (diamine oxidase) which breaks down any histamine that we absorb from a histamine-containing food. When we eat a food which contains histamine it does not affect us. However, some people have a low level of this enzyme. When they eat too many histamine-rich foods they may suffer ‘allergy-like’ symptoms such as headaches, rashes, itching, diarrhoea, and vomiting or abdominal pain. This is called histamine intolerance.

Foods that are particularly high in histamine and other vasoactive amines include:

• Champagne, wine, beer, cider and other fermented drinks and spirits
• Sauerkraut and other pickled foods
• Vinegar and foods containing it such as dressings, pickles, mayonnaise, ketchup, mustard
• Tofu and soya sauce
• Parmesan cheese and other cheeses
• Sausages and other processed meats (ham, salami, gammon, bacon)
• Mushrooms and quorn
• Tinned and smoked fish (tuna, salmon, herring) and crustaceans
• Prepared salads
• Tinned vegetables
• Dried fruit, seeds, nuts
• Yeast extract, yeast
• Chocolate, cocoa, cola

Certain foods (even food that is low in histamine) can stimulate the release of histamine from mast cells in your body (a type of immune cell). These foods include:

• Bananas
• Tomatoes
• Strawberries
• Nuts
• Peanuts
• Shellfish
• Egg white
• Chocolate
• Pumpkin
• Spinach
• Aubergines
• Avocado
• Papayas
• Kiwi
• Pineapple
• Mango
• Raspberry
• Tangerines
• Grapefruits
• Red prunes
• Pea
• Spices

It should be noted that allergy tests measuring IgE levels, such as skin prick testing and specific IgE blood tests for these foods will be negative. This is because reactions to histamine are not caused by an IgE food allergy – the cause is histamine intolerance.

Diagnosis of histamine intolerance is usually made by a person trialling a low-histamine diet for a couple of weeks, and seeing if their symptoms improve. Blood tests that claim to be helpful in measuring levels of histamine or the level of the enzyme that normally breaks histamine down are not reliable.

Treatment consists of avoiding histamine-rich foods but only to the level that is required by an individual. The amount of histamine rich foods tolerated will vary from person to person. Taking a regular antihistamine is often helpful.

Food exclusion should always be followed by a period of reintroduction in order to confirm a diagnosis. If this is not done the diet can easily become over restricted and unmanageable. At worst it can become nutritionally deficient.

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Alcohol Intolerance

It is not unusual to experience allergy-like symptoms following ingestion of alcohol. The reaction can be very specific, for example to a certain type of wine, or can be caused by different types of alcohol.

True allergy is caused when the body mistakenly makes antibodies against a substance, which causes a reaction next time the substance is taken.

True allergy to alcohol is extremely rare, although cases of skin rash reactions have been recorded. More often, the alcohol molecule exacerbates underlying conditions such as asthma, urticaria and rhinitis because it opens up blood vessels. Allergic people may get wheezy, headaches and skin flushes.

More commonly, symptoms are caused by an intolerance to alcohol, or to the food on which the drink is based (e.g. grapes for wine, grains for whisky etc), or to another substance in the drink (see below). An intolerance may arise when the body is lacking an enzyme that is needed to properly digest and eliminate a food or substance (or in this case, the alcohol itself). If the alcohol molecule cannot be effectively dealt with by the body, it can cause unusual symptoms to occur.

Alcohol also increases the permeability of the gut, which allows more food molecules into the body. This may explain the reactions of mildly food sensitive individuals who may not react to the food alone but only when it is combined with alcohol.

Red wine seems to cause the most problems, followed by whisky, then beer and then other wines. Most frequently, the likely cause of a reaction is not the alcohol itself but the chemicals - congeners - which give the drink its body, aroma and flavour. Again, the reactions are only rarely true allergic reactions.

Some of the major culprits are:

Histamine

This is present in many alcoholic drinks, particularly red wines and can cause headache, flushing, nasal symptoms, gut symptoms or asthma. Some people are particularly intolerant of histamine because of a deficiency in the breakdown and elimination of histamine from the body.

Yeasts

Yeasts are a possible cause of a true allergic reaction to alcoholic drinks. However, studies show that there are only low levels of yeast allergens present in alcoholic drinks.

Sulphites/Sulphur Dioxide

Sulphur dioxide is particularly common in home brewed-beers and wines as sodium metabisulphite. This is used in the cleansing of equipment and remains in very high levels and resulting brew. Around 1 in 10 asthmatics are sensitive to sulphites and may have a wheezy reaction to alcoholic drinks. Rashes and anaphylactic reactions are rare.

Additives

Additives e.g. tartrazine, sodium benzoate - can trigger urticaria and asthma.

Plant-Derived Allergens

The fruit (grapes, apples, juniper berries, coconuts, and oranges), flavours (hops) or grain (malt) from which the drink is made can also be the cause of a true allergic reaction. However, fruit and other plant-derived allergens are mostly destroyed by processing. One unusual potential source of trouble is fungal spores (mould) from the corks of wine bottles. Sensitivity to this fungus is rare. However, if you are sensitive and draw a cork with visible mould, you potentially expose yourself to a dose of allergen. Running the neck of the bottle under a cold tap before drawing the cork would probably be the best way of dealing with this.

At present, avoidance is the only real way of controlling symptoms arising from allergy or intolerance to alcoholic drinks. If you suspect you are reacting, make a note of the type of drink (and anything else consumed at the same time) and whether or not you took exercise. If all alcoholic drinks affect you, it is probably an exaggerated response to the alcohol itself or an exacerbating effect on your underlying condition. If not, try to narrow the field down to specific drinks or drink/food combinations, so that you can avoid the culprits.

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Yeast Intolerance

The following information will help you to avoid yeast in your diet.  If your symptoms have not improved after six weeks of strict avoidance, you should reintroduce yeasts back into your diet.

Bread and cereal products containing yeast

These products contain a form of yeast known as baker’s yeast:Most breads, rolls, croissants, Danish pastries, doughnuts, Chelsea buns, bath buns, some American muffins, crumpets and muffins.

These products are usually yeast free but you should always check all ingredients labels, as this is not always the case:Soda or scofa bread, pitta bread, chapattis, naan bread, most crispbreads and crackers, rice cakes.

Alcohol

The following alcoholic drinks contain brewer’s yeast:Beer, wine, cider.

Stock

Most stock cubes and gravies contain yeast.  Vegetarian brands are available without yeast (check labels).  Bovril, Oxo, Marmite, Vegemite, and other brands of yeast extracts.

Vinegar and salad dressings

Pickles, mayonnaise, chutneys, and any food containing vinegar such as salad dressings, will contain yeast.

Fermented or ripe foods

There is a form of yeast that is naturally present on ripe fruit and vegetables and pre-cooked foods.  Also present in dried fruit, malt, buttermilk, sour cream, synthetic cream, yoghurt, over ripe fruit, tofu, ‘left-over’ food, ripe cheeses, sauerkraut, soy sauce, and miso. Anything that has been opened and stored for a long period, e.g. jams may develop yeasts on the surface.

Vitamin-B tablets unless marked "yeast free".

Other sources of yeast (check all food ingredient lables carefully)

Quorn (mycoprotein), hydrolysed protein, hydrolysed vegetable protein or leavening (check labels).  Monosodium glutamate, sometimes citric acid.

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Wheat and Gluten Intolerance

Wheat intolerance differs from coeliac disease.  Coeliac disease is a lifelong intolerance to gliaden, part of the gluten proteins that are a large part of the grain of wheat, rye and barley.  It causes damage to the small intestine and many other symptoms and tends to run in families.  Strict adherence to a gluten-free diet brings complete resolution of symptoms.

Those with wheat intolerance will still experience adverse symptoms from gluten free products, as the remaining part of the wheat will be affecting them.  They may, or may not, be able to eat rye, barley and oats, that are part of the wheat family. As with many other food intolerances, they may be able to reintroduce wheat back into the diet after a period of elimination.

Foods containing, or possibly containing, wheat

Bread and baked foods

All loaves, including pumpernickel, and rolls unless specifically stated.  Many "rye" and "corn" loaves contain some wheat.  Pitta,  crumpets, muffins, tortillas, and tacos (should be corn but mostly wheat in UK), doughnuts, cakes, cookies, biscuits, crackers, croutons, packet snacks, rusks, waffles, pancakes, crepes, pizzas, pretzels, breadsticks, communion wafers, pasta and pastry.  Also yorkshire pudding, suet pudding and many other puddings.

Cereals

Most cereals will contain some wheat.  The exceptions are porridge oats, corn flakes, rice krispies and granola. Always read the labels.

Flour and pasta

All of these will contain some wheat unless stated to be wheat free or buckwheat, which is not from the wheat family.

Meat and Fish

Burgers, rissoles, salami, sausages, corned beef, luncheon meat, liver-sausage, continental sausages, pates, meat and fish pastes and spreads, ham, fish and scotch eggs coated with breadcrumbs.

Vegetable products

Vegetable pates and spreads, vegetables coated in breadcrumbs, e.g. onion rings, vegetables tempura, tinned beans, (also tinned spaghetti, often grouped with vegetables), soups and tinned and packet snack or ready prepared foods.

Sauces and condiments

Gravy, packet and jar and bottled sauces, casserole and ready-meal mixes, stock cubes and granules, ready prepared and powdered mustard, stuffing, baking powder, monosodium glutamate, some spice mixes (check label).

Desserts

Most puddings, pastry, yogurts containing cereal, ice cream, pancakes, cheesecakes and others with a biscuit base.

Beverages

Malted milk, chocolate, Ovaltine and other powered drinks.  Beer, ale, stout, larger, Pils lager, whisky, malt whisky, gin, most spirits and many wines.

Confectionery

Liquorice, chocolate, chocolate bars and most wrapped bars. Other sweets (check labels).

Medication

Many prescribed and over the counter drugs contain wheat.  Check with your pharmacist.  Do not stop prescribed medication without discussing with your doctor.

Other

Glue on labels and postage stamps.

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Alternatives to wheat

Cereal & grain

Maize (corn), maize (corn) flour, potato, potato flour, rice, rice flour, soya beans, soya flour, millet, buckwheat, sago, tapioca, quinoa, sorghum, arrowroot, gram (chickpea) flour and lentil flour. Chickpeas, beans and lentils are good fillers and can be added to soup.

Wheat-free pasta is available in large supermarkets and health food stores.

Baking powder, Bicarbonate of soda, cream of tartar.

Meat & fish

All fresh and frozen meats and fish without coatings.

Desserts

Rice, sago or tapoca puddings, jellies, sorbets, gelatine or vege-gel based desserts.

Seasonings, sauces & condiments

Pure spices, salt, freshly ground pepper, french mustard. Home-made mayonnaise and dressings. Sauces prepared with cornflour or other alternative flour.

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Additional Information on a Wheat – Free Diet

Other names for wheat products that may be listed on labels:

• Durum wheat, spelt (triticum spelta), kamut (triticum poloncium)
• Couscous
• Bran, wheat bran, wheat germ, wheat gluten
• Farina
• Rusk
• Semolina, durum wheat semolina
• Flour, wholewheat flour, wheat flour, wheat starch
• Starch, modified starch, hydrolised starch, food starch, edible starch
• Vegetable starch, vegetable gum, vegetable protein
• Cereal filler, cereal binder, cereal protein.

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Dairy Intolerance

There are many reasons why milk might need to be avoided.  It may be because the protein component of milk is not tolerated or because the milk sugar (called lactose) is not tolerated.  If you are unsure which component of milk you do not tolerate then it is preferable to avoid both and to follow a milk free diet.  This includes cows’ milk and all other animal milks such as sheep, goat and buffalo etc.

It is not just milk that should be avoided but also dairy products and foods made with milk derived ingredients. 

It used to be very difficult to identify all milk derived ingredients, but with improvements in food labelling due to changes in European Food Labelling law, foods which are manufactured will now clearly list if milk or a milk derived ingredient is contained in manufactured pre-packaged foods or drinks.  At the moment this is not the case for foods that are sold loose such as delicatessen, butchers products or bakery items, but this will change in 2014 when new regulations become mandatory.

If you are shopping outside the EU you will need to know all the names of milk derived ingredients to be able to check food labels:

• Milk powder/skimmed milk powder
• Milk drinks /malted milk drinks
• All types of cheese/cheese powder
• Butter
• Margarine/low fat spread unless it specifically states it is dairy free)
• Yoghurt/quark/fromage frais
• Cream/sour cream
• Casein/caseinates/sodium caseinates/hydrolysed casein
• Milk solids
• Non-fat milk
• Whey
• Whey syrup sweetener
• Milk sugar solids
• Lactose

ANY food can contain milk so it is essential that the full ingredients’ listing is read for all manufactured products.  It is not sufficient to read just the allergy advice box.

Non-packaged items should be avoided as their ingredients are unknown and they may contain milk or milk derived ingredients.

When following a milk free diet for the first time it is easy to make mistakes and try and take shortcuts but with so many foods containing milk derived ingredients there is no substitute for carefully reading food labels every time a new food is used. 

Often people new to this diet are surprised to find out that many of the following foods CAN contain milk derived ingredients.  However, some brands may not, so check every food label or you may be restricting your diet unnecessarily.

The following are examples of processed foods, which may contain milk:

• Breakfast cereals
• Soups
• Baby foods
• Processed meats, e.g. sausages, pate, meat pies
• Pizzas
• Sauces and gravies
• Baked goods, e.g. bread, rolls, buns, brioche
• Pancakes, batters
• Ready meals
• Puddings and custards
• Cakes, biscuits, crackers
• Chocolate and confectionery
• Crisps, flavoured nuts and tortillas
• Any manufactured food, bakery, butcher’s products or deli items

Note:  Before any changes are made to yours or your child's diet, you should seek advice from a dietitian.

It is worth noting that just because one brand of food contains milk, a similar food of a different brand may not so keep checking those labels.  Also, the cheaper value, or essential brands can often be milk free whereas the luxury versions are more likely to contain butter and cream.

Is there a difference between soy formula milk and soya milk?     

Yes, the soya milks available in shops and supermarkets are unsuitable for babies under 12 months, as they lack sufficient nutrients for babies - especially protein, fat and iron.  Infants under 12 months require either breast milk or formula milk.  Formula milks are designed specifically to meet the nutritional requirements of growing infants and are formulated to be as close to breast milk as possible.

Can soy formula milks be used during weaning, either as a drink or in recipes?

Yes, soy formula milks can be used during weaning both as a drink and in recipes to replace cows’ milk,  but not in babies under six months of age unless there is a specific medical indication.  It is thought that some substances in this milk called phytoestrogens, which are similar to the female hormone oestrogen, may affect the development of children.  For the infant who struggles to take the 500-600mls daily intake of milk/replacement milk, the formula can be used to make custard, rice pudding, added to soups, white sauces, purees etc

I have heard that cows’ milk is an important source of calcium.  If my baby must avoid cows’ milk, will he/she get enough calcium?

Soy formula milks are fortified with calcium, and one pint (500-600mls) will provide about 60% of the daily requirement of calcium for babies under one year.  The balance of the calcium should also be obtained from milk free foods at weaning, such as cereals, bread, sardines, broccoli, soya yogurt, dairy free rice pudding and custard etc.  Occasionally, calcium supplements may be necessary if a baby is not taking a sufficient amount of soy formula milk and calcium rich solids .  If you are concerned about your baby's calcium intake, ask your dietitian or doctor for advice.

Are soy formula milks suitable for older children and adults?

Yes, although they are low in calcium for infants over 12 months so it may be preferable to move onto an off-the-shelf soya milk, which is, calcium enriched to 120mg calcium per 100mls.  It depends on the overall dietary intake and what is acceptable to the infant.

Even if I check the labels thoroughly, how can I be sure that specific manufactured foods are suitable for someone who cannot tolerate cows’ milk

Food allergen labelling laws are strictly followed by manufacturer.  As long as you are reading food labels every time you shop to make sure ingredients have not changed,  you should be safe.  Avoid any foods that do not have labels.

We prefer a vegan diet.  Can we give our baby a soy formula instead of a formula based on cows’ milk?

Yes, it is free from animal products, so, parents who prefer to give their babies a vegan diet can use it.

A small number of children will react to soya formula and therefore will need to be prescribed a formula which is free from both cows’ milk protein and soya protein.  Your GP or dietitian will advise on suitable alternatives.

If you or your child are milk allergic then specialist advice is required because although the majority of children do "outgrow" their allergy, not all will.  For those that do out grow it, they can reintroduce cows’ milk into their diet but this is not recommended without advice from a specialist.  If milk is reintroduced and the milk allergy or intolerance has not been outgrown this could cause potentially life threatening symptoms in some individuals.

Lactose Intolerance

This is a relatively common complaint, perhaps one in five people will suffer symptoms suggestive of lactose intolerance and this is a lot more common in certain ethnic groups.  This is not an allergic condition, but an inability to digest lactose (milk sugar) because of low levels or an absence of lactase the enzyme responsible for digesting lactose.  It can affect both children and adults, and the common symptoms are diarrhoea, bloating and discomfort.  Lactose intolerance may occur temporarily following a bout of gastroenteritis and in these cases will usually resolve over time.  Other cases will be lifelong such as those born with a primary lactose intolerance or those who grow into it.

Lactose is present in all mammal milks such as cows’ milk, goats’ milk, buffalo milk and sheeps’ milk in similar quantities.

For some people there is a dose related response, someone may be able to tolerate the small amount of milk in tea, but a glass of milk would cause symptoms. 

There are tests available for the diagnosis of lactose intolerance, however the most reliable diagnosis is to exclude lactose to see if the symptoms get better and then reintroduce it to see if the symptoms return.  A dietitian should help with this to ensure it is done correctly and monitored and supervised.  Your GP will be able to refer you to a state registered dietitian on the NHS.

If, after having excluded dairy products from your diet for a period of time (e.g. a month) without improvement in your symptoms, then it is likely there is some other cause or possibly an additional cause of your symptoms.  If dairy is not the trigger it is advisable to reintroduce dairy products back into the diet.

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Calcium

It is recommended that older people have a calcium intake of 1500 mg per day.  The daily recommended calcium intake according to age, as recommended by the National Osteoporosis Society, is as follows:

Age	Daily Calcium Intake
Children:
up to 12 months	525mg
1-3 years	350mg
4-6 years	450mg
6-10 years	700mg
11-18 years	1000mg
Adults:
Males	1000mg
Females	800mg
Breastfeeding mothers	1250mg

Milk and dairy foods are excellent sources of calcium but many dairy free foods are also high in calcium – often because it has been added during production.

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Non-Dairy Sources of Calcium

The following are foods that have a high calcium content

Food	Calcium content per 100g/100ml
Calcium enriched soya milk, oat milk, hemp milk, coconut milk, almond milk, hazelnut milk	120mg
Chick peas (raw)	160 mg
Soya beans (raw)	240 mg
Tofu	510 mg
Red kidney beans	100 mg
Okra	160mg
Spring greens	75mg
Watercress	170mg
Parsley	200mg
Apricots	92mg
Currants	53mg
Figs (dried)	250mg
Almonds	240mg
Brazil Nuts	78mg
Hazel Nuts	140mg
Treacle (black)	500mg
Tahini	680mg
Sesame seeds	670mg
Orange juice with added calcium	100mg
Instant porridge 40g made with calcium enriched plant/nut milk	600mg
Calcium enriched bread	240mg per thick slice

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