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Compatibility of foodstuffs

The freshness factor: origin and conditions of histamine formation

In contrast to other food intolerances, histamine intolerance has an important peculiarity: Freshness is often a decisive factor in determining whether a food is tolerated or not. As a rule, completely fresh foods contain only insignificant amounts of histamine. In most animal and plant organisms, histamine is only produced when it slowly decomposes after death (proteolysis) or is decomposed by germs (microorganisms). Often, therefore, foods cannot be clearly divided into tolerable and intolerable ones, but under certain circumstances they are tolerable and in other cases not. This is another reason why histamine intolerance is probably one of the most complicated food intolerances of all. Here we want to try to give help for the assessment of the histamine content of food. The following influencing variables are important for the formation of histamine:

Protein content and amino acid composition: Histamine is a degradation product of the amino acid histidine. Amino acids are the building blocks of proteins and peptides. The higher the content of proteins, peptides and amino acids and the higher the proportion of the amino acid histidine compared to other amino acids, the more a food tends to form histamine. Nevertheless, foods rich in histidine do not generally have to be avoided, because the formation of histamine from histidine requires interaction with other factors:

Perishability: Due to the involvement of microorganisms, the more perishable a food is, the faster histamine is produced. A food is easily perishable if it has a nutrient composition that is favourable for microorganisms (this includes above all a high protein:carbohydrate ratio) and if, at the same time, the microorganisms have ideal growth conditions (humidity, heat, air). Good cooling is therefore very important for the storage of perishable foods.

Hygiene: Microorganisms (bacteria, yeasts) are present everywhere, on surfaces and in the air. The more germs are present in a foodstuff, the faster the histamine formation will proceed.

Storage time: The longer food is stored, the more time microorganisms have for the formation of histamine. Furthermore, proteins can also slowly decompose in perfectly preserved products without the influence of microorganisms (proteolysis).

Basic rules

Prepare your own meals from fresh, unprocessed raw materials. Ensure a short storage period. Perishable products must be cooled well without interruption. Be very careful with canned or semi-preserved food! Convenience foods (ready meals, tinned or packaged foods) are usually not suitable. All foods that have been treated by microbial maturation processes (fermentation) tend to be particularly rich in histamine. Examples are long matured hard cheese, salami, sauerkraut, beer, wine, must and other fermented fruit juices. Even if such deliberate and controlled maturing processes actually serve to refine or preserve a product, decomposition or spoilage processes take place, which can lead to considerable poisoning in histamine-intolerant persons.
Important: Histamine is both resistant to heat and cold (thermostability). It cannot be destroyed by cooking, baking or freezing. Once histamine is formed, it cannot be removed anymore. Its formation must therefore be prevented from the very beginning.

On the page Therapy > cooking advice you will find further important information on the subject of freshness.

Fish, sea food

Absolutely freshly caught fish contains hardly any biogenic amines. However, fish is easily perishable and some fish species contain a lot of histidine (e.g. tuna, mackerel, sardine). Fish and fish products therefore tend to produce histamine particularly quickly and productively, so that enormously high histamine concen­trations can be achieved.

Fish can be enjoyed without any concerns if it is consumed absolutely fresh from the catch, or if it is processed and frozen on the ship immediately after catching. The cold chain must never be interrupted during transport and storage. It is also important that the fish is thoroughly gutted immediately after capture under hygienic conditions, because bacteria in the dead fish can penetrate from the gut into the surrounding tissue. Tuna products in particular should be avoided strictly. Tuna is caught in warm waters. It often lies uncooled and unprocessed in the fishing boat at the heat until it arrives at the harbor.

Note: Absolutely fresh fish (not from the shop counter but directly from the fisherman or from the fish farm), as well as frozen fish with white meat are well tolerated. It is better to do without all other fish or to be very careful!

Crustaceans / shellfish (mussels, crabs, lobsters, shrimps, prawns) as well as seafood (invertebrates) are not only easily perishable, but also contain histamine liberators, which is why they can be incompatible even when fresh!

If you do not eat fish at all, you can take capsules with fish oil as a dietary supplement to supply yourself with the important omega-3 fatty acids. Due to the poor fat solubility of histamine, professionally produced fish oil is harmless with regard to histamine. As an alternative to fish oil, pure vegetable capsules with omega-3 fatty acids are also available in pharmacies. Rapeseed oil is also a good supplier of such healthy fatty acids.

Ciguatera fish poisoning (CFP) is a completely different type of fish poisoning. At the beginning it can easily be confused with histamine poisoning (or poisoning with other biogenic amines respectively), but has other causes: Ciguatoxin and maitotoxin, two very strong toxins produced in tropical waters by certain dinoflagellates, can accumulate in the food chain. Normally non-toxic edible fish can thus become seasonally and regionally toxic without being predictable.

Meat, poultry

Avoid canned, salted, dried, marinated, smoked or otherwise preserved meat or meat preparations and meat which has been minced or pureed. This includes all sausage products (salami, sausages, ...), cold cuts, dried meat, dry-cured ham, sandwich spreads and the like, as well as processed products and convenience foods containing meat. Innards / offal should also be avoided.

Use fresh fresh meat, which you buy raw, unseasoned, unmarinated and uncured and season yourself (cutlets, steaks, fillets, poultry, ...). Pre-packed meat (preferably vacuum-packed) should be preferred to open sale because airtightness and better hygiene delay the formation of histamine. In open sales, there is no control over the consumption date and the meat comes into increased contact with germs by touching it and through the air. There have also been cases where packaged goods were systematically unpacked shortly before the consumption date expired and offered at open sale counter (e.g. Coop Switzerland, discovered by Swiss TV in 2011).

Do not store meat for too long after purchase (preferably use it a few days before the expiry date) and consume or deep-freeze it immediately after preparation.

The histamine content tends to increase with the reduction ratio (degree of comminution). Sliced meat is still ok, minced meat quickly becomes incompatible. Minced meat is unproblematic if you have it freshly produced by the butcher from fresh raw material right before your eyes or if you produce it yourself and then consume it immediately. A delivery packaged in a modified atmosphere and freshly delivered to the shop may already contain too much histamine in some cases.

Strictly speaking, fresh meat is never completely "fresh". Meat is not sold immediately after slaughter, but must be left to rest for a few days (up to two and a half weeks) at 1 to 3°C to make it fit for human consumption. This process of meat ripening is called meat hanging. If carried out properly, only insignificant amounts of histamine are produced, so that fresh meat delivered to the shop is usually sufficiently tolerated. Exceptions can be: meat hung for a long time (e.g. a well hung steak) or also game meat (deer, stag, chamois). Game meat is sometimes subjected to lactic acid fermentation and can therefore contain too much histamine (wild boar is probably OK).

Most bacteria sit on the surface of the meat and produce histamine there. Histamine is very soluble in water. If you have slight doubts about the freshness of a piece of meat, at least the histamine present on the surface can be washed away under the running cold water or by watering it. Then drain, wipe off the water and dab dry with kitchen paper. Do not put wet into the hot frying pan, otherwise the frying fat will splash off (risk of burns, cleaning required)!

Depending on your individual sensitivity, you can maybe find some meat preparations that are sufficiently compatible in your case. The frequently used E250 is compatible but should not be consumed too frequently for other reasons (e.g. it blocks iodine uptake into the adrenal gland). Avoid preservatives and flavour enhancers (glutamates, yeast extract, flavor enhancers).

If, depending on the severity of the disease, even fresh meat is too often intolerable, taking supplementary diamine oxidase before meals helps quite well.

Eggs

Eggs seem to be well tolerated by the majority of those affected. Some, however, react to egg white with symptoms (in some cases even after cooking it well). Be aware that this can also be chronic inflammatory pain that appears very slowly, so that a temporal connection with egg consumption is often hardly recognizable. Egg yolk, on the other hand, does not cause any problems as far as we know. The usual separation of egg yolk and protein in the shell halves is clean enough to enjoy the egg yolk without hesitation. If you are highly sensitive or want to be absolutely sure, you can also rinse the egg yolk with water.

According to our experience, quail eggs are also well tolerated by those who do not tolerate egg white from the common chicken (Gallus gallus domesticus). Unfortunately, the quail eggs are small, expensive and difficult to obtain.

It is possible to do without eggs completely, without having to fear malnutrition, as long as you eat as varied a diet as possible and consume other animal products (meat, dairy products).

We do not know which substance in egg white is responsible for the symptoms. However, it is obviously only found in egg white, not in egg yolk, and it is heat-resistant, so that even long and thoroughly cooked egg white can still cause symptoms. Ovomucoid, a very aggressive egg allergen that is responsible for some of the chicken egg allergies, also has these properties. Whether there is a connection with ovomucoid and whether it is a non-specific mast cell activation has not been clarified.

Milk, dairy products

Milk

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Cheese

Fresh ( = unripened) cheese (curd, cottage cheese, mozzarella, boursin, fresh goat cream cheese, etc.) is well tolerated, but unfortunately not so intense in taste. Long matured cheeses (hard cheese, soft cheese, processed cheese), on the other hand, can contain a lot of histamine and in extreme cases develop into true histamine bombs. Noble mould cheese is mostly problematic, depending on variety, manufacturer, degree of ripeness individual sensitivity to histamine. For hygienic reasons, there is a greater risk of undesirable bacteria multiplying in raw milk cheeses than in heated milk cheeses.

According to Steneberg, histamine-rich cheese is tolerated much better than histamine-rich fish. One explanation could be that biogenic amines from cheese are released relatively slowly in the gastrointestinal tract [Steneberg 2007].

Always read the list of ingredients for cheese! Many types of cheese and cheese preparations contain additives or ingredients, some of which can be incompatible.

Milk substitutes

Rice milk is not completely histamine-free because it is made slightly sweet by a fermentation process. The situation is probably similar for millet milk and oat milk, but they could be worth a try. Coconut milk and coconut water are well tolerated (but not suitable for daily use because of their high selenium content). Soy milk is incompatible.

Insects

Insects have been used as food sources in some parts of the world since primeval times. In other countries they are not permitted as food, or they have only recently been approved for individual species. In Switzerland, for example, crickets, mealworms and locusts have been approved since May 2017. In Europe, the trend to eat insects is still new. Only few can overcome their inhibitions to eat insects as long as they are considered as disgusting in some cultures. We do not yet have any meaningful empirical experience on the compatibility of insects with MCAD/HIT. Therefore only a few theoretical considerations to the topic for now:

Histamine content? The ability to form histamine in the living organism (histamine biosynthesis) is generally widespread in the animal kingdom. We have only very incomplete knowledge about the respective properties of insects. However, histamine is certainly contained in bee venom and in the salivary gland secretion of stinging insects.

Histamine formation depending on freshness? Insects are protein-rich and perishable. Thus, the formation of histamine after death could probably be comparable with other animal foods (e.g. meat) depending on freshness. Insects are consumed together with their intestines. If they are not heated or otherwise preserved immediately after death, intestinal bacteria (as is known from fish) could migrate into the tissue and decompose it. If, on the other hand, they are deep-fried immediately after killing, the heat, the reduction in water content and the surrounding fat could perhaps protect them so well from spoilage for a while that they might even have a clear advantage over meat. This means that depending on the method of preparation, insects may be sometimes more and sometimes less perishable than mammalian meat. In any case, we assume that the (hist)amine content of insects is also highly dependent on freshness.

Histamine liberators? DAO inhibitors? We do not know which insect species contain histamine liberators or DAO inhibitors at which developmental stages. It is known that hymenopteran stings are very strong mast cell activators. There are also numerous insect species that produce very unusual chemicals (up to the highly explosive cocktail of the Brachininae ("bombard beetle"), so that it must be assumed that the different chemical composition also has a different tolerance than that of mammalian meat. Occasionally, people may have an allergic reaction to insects that are unintentionally present in food (e.g. beetles and spiders harvested accidentally with grapes and whose proteins are still detectable in grape juice and wine). Historically, insects are much more closely related to molluscs and crustaceans (which often are mast cell activating) than to mammals. It must therefore be assumed that insects not only have an (already proven) allergenic potential, but could also be mast cell activating, depending on the species.

Grain products, starchy side dishes

Wheat intolerance

In histaminosis or mast cell diseases, a temporary or permanent intolerance of wheat and, to a lesser extent, of other gluten-containing cereals is often, but not always, observed, without a laboratory or biopsy diagnosis of celiac disease / sprue [Homann et al. 2010b, p.196], and without wheat allergy being detectable. Possible symptoms are mainly flatulence, restless digestion, abdominal pain or diarrhoea. Other possible symptoms include headache, migraine, lethargy, fatigue, attention deficit disorder and hyperactivity, schizophrenia, muscle pain, bone and joint pain. Due to increasing wheat intolerance, the demand for spelt and gluten-free products has recently increased significantly. Little is known about this phenomenon. It is also not yet clear whether it is related to histaminosis or whether it is an independent mechanism. The following explanation attempts are discussed:

The gluten and gliadin hypothesis (gluten sensitivity, gluten intolerance)

The tolerance of cereal products correlates quite well with the gluten content and is dose-dependent. Under a gluten-free diet an improvement can be achieved up to and including freedom from symptoms. Therefore it is suggested that a gluten sensitivity could be the cause for the wheat intolerance observed more and more frequently in the last years. Gluten is a group of proteins that serve as a store for the seedling in the grain. This is the "adhesive protein" that makes the dough elastic and gives baked goods good baking properties ("wheat glue"). For this reason, new wheat varieties with the highest possible gluten content have been bred in recent decades. Certain gliadins are suspected of triggering the symptoms. Gliadin is the part of gluten that is soluble in alcohol (ethanol). The gliadin epitope Glia-alpha9 is supposed to trigger very strong intolerance reactions and Glia-alpha20 weak intolerance reactions. Glia-alpha9 are particularly highly enriched in modern high-baking bread wheat varieties, which could explain why products from original spelt or old bread wheat varieties are well tolerated. [Lindhauer 2013]
Further information:

Wikipedia: Non-celiac gluten sensitivity (NCGS) or gluten sensitivity

The ATI-Hypothesis (Amylase/Trypsin Inhibitors, Adenosine Triphosphate Amylase)

iIt has become increasingly clear in the last few years that it is possibly not gluten but another protein fraction of wheat that causes symptoms in many people. It is a group of proteins known as alpha-amylase trypsin inhibitors (ATI) (also often referred to as adenosine triphosphate amylase) [Tilg 2013; Junker et al. 2012; Prescott et al. 2005]. These proteins are naturally produced by plants in very small amounts. They serve as reserve proteins for the seed and may also provide some protection against insects [Altenbach 2011; Mansueto et al. 2015].
However, these proteins also have two properties that humans have taken advantage of: 1) They are nutritionally valuable for humans because of their balanced amino acid composition. 2) They inhibit certain digestive enzymes (amylases to digest starch and protease/trypsin to digest proteins). This makes the seeds toxic to feeding pests.
Because of these useful properties, many grain varieties have been raised to the highest possible ATI content, so that today this is many times the original amount. Thanks to the "natural" insecticide ATI, the modern high-performance varieties are more resistant to pests and yield more than the old varieties. In the meantime, hardly anyone cultivates the old varieties anymore. ATI has not only been crossed with wheat. The different types of grain can be crossed with each other. Spelt and other species often have ATI crosses as well.

Researchers have now shown that ATI activates the innate immune defence in humans and probably causes intolerance reactions in this way [Junker et al. 2012; Mansueto et al. 2015]. However, humans also digest their food with amylases and proteases. What effects does the inhibitory effect of ATI have on our digestive enzymes? Can undigested starch reach the large intestine? See also this document about the genetic defect HLA-B27 (in German) and its secondary diseases (Klebsiella miscolonisation, rheumatism, inflammation, irritable bowel syndrome, Crohn's disease, ...).

The ATI varieties are usually the same as those bred for a high gluten content. This may by why gluten is suspected as the culprit – incorrectly in some cases. It has also already been possible to use genetic engineering to make other crops insect-resistant thanks to ATI. As far as we know, they are not yet on the market because of certain "initial difficulties" (e.g. genetically modified ATI peas have proved toxic to mice in animal experiments), because of legal hurdles and because of the negative attitude of consumers. However, intensive research is being carried out and it is probably only a matter of time before genetic engineering and conventional breeding will give us a leap in development that will make it even more impossible to find out which of these many untested innovations are making us increasingly ill.
How can ATI be avoided in nutrition? There is no need to declare on the product packaging which cereals have been used. Consumers are therefore unable to tell whether a product contains ATI cereals or not. The safest way is to switch to a gluten-free diet, as gluten-free foods certainly do not contain ATI cereals. Since the effect is dose-dependent, however, it is sometimes sufficient to simply eat less grain and prefer old varieties (spelt, emmer, einkorn). [Tilg 2013; Junker et al. 2012; Altenbach 2011; Prescott et al. 2005]

Storage time?

Some cereals are stored for up to ten years in compulsory stocks to ensure security of supply in the event of a crisis. Further storage time is added at the manufacturer, in the distribution centre, in the shop and then at the end consumer in the warm kitchen cupboard. We do not know whether such long storage periods also contribute to the observed incompatibility of grain, as the products do not show the year of harvest of the grain used.

Irrespective of which hypothesis is correct, it is true that those who tolerate wheat (and other cereals) need not avoid them in histaminosis. Anyone who develops symptoms should limit their consumption and have the cause clarified by an allergologist. If no cause is found, this could be one of the mechanisms mentioned above.

How do I avoid incompatible cereals?

Here are a few rules of thumb - that do not necessarily apply in every case:

• Reduce the amount consumed because the symptoms are dose-dependent.
• Wheat is badly tolerated, but possibly also rye, barley etc.
• Well-tolerated starch suppliers are millet, old varieties (original spelt, original rye, einkorn, emmer, kamut), rice, potato, sweet potato, sweet corn, oats.

In our experience, when the digestive tract is no longer irritated – for example, after several weeks of a histamine elimination diet - the intestinal wheat seems to be better tolerated.

Yeast pastry and sourdough

With yeast pastries and sourdough there is great disagreement as to whether they are compatible or not. Yeast is often said to contain histamine. This does not necessarily have to be the case, however, but yeast-containing products are often reasonably well tolerated. Only one species (Saccharomyces cerevisae) is actually used as baker's yeast, so that the reason for the different tolerance of yeast pastries is probably not to be found in the use of different yeast types or yeast strains. Our attempt to explain: Probably the production process is the decisive factor. Yeast itself does not have to be histamine-containing per se, but produces histamine during the time it is active. The longer the yeast dough is kept warm so that the yeast works and the dough rises, the more histamine it forms during this time. The airier a pastry is, the more histamine one can tend to suspect in it. It is probably exactly the same with sourdough. Here it is lactic acid bacteria and special sourdough yeast (e.g. Candida humilis) that cause the dough to rise through fermentation. In addition to lactic acid and acetic acid, lactic acid fermentation also produces various amino acids / amines (histamine). The more time the microorganisms have for reproduction and fermentation, the more histamine is likely to be contained in the final product. The glutamic acid content of yeast could also influence the tolerance (glutamate).

Yeast is contained in most bakery products. Free from yeast can be e.g. shortcrust pastry, puff pastry, cake dough and individual types of biscuits (note ingredients declaration). If you want to avoid yeast, you can eat muesli instead of bread for breakfast (see below).

Attention: Yeast extract is not the same as yeast! See the section on yeast extract!

Pasta

Those who do not tolerate egg white (histamine liberator) must avoid egg pasta and should limit themselves to products without eggs.

Those who do not tolerate wheat will certainly be able to find pasta made from better-tolerated cereals such as spelt, rye, einkorn, emmer, kamut, or from rice, maize semolina or maize starch. Not only in health food shops, but often also in supermarkets. The compatibility of the individual grain types can vary individually. Try out what works best for you.

Cereals, cereal flakes, muesli

Muesli is quick and easy to prepare, healthy and saves cooking. Millet flakes, oat flakes and sometimes spelt have proven to be well tolerated. In addition some milk and compatible fruits / berries / jam / sugar.

Malt: Cornflakes almost always contain malt extract and are therefore only conditionally tolerated. Note: Maltodextrin is not a malt, but a well tolerated thickening agent.

Folic acid, vitamin B2: Oat flakes, cornflakes and other cereals are often artificially enriched with vitamins. In our experience, products with artificially increased levels of folic acid, vitamin B2 (riboflavin, E101) and possibly vitamin B3 (nicotinic acid, niacin) are poorly tolerated. Always read the list of ingredients carefully.

Vegetables

The incompatible vegetables listed in our food list should be avoided or replaced with well-tolerated vegetables. Both fresh and frozen vegetables are suitable. Since raw vegetables are still living tissue that can keep itself low in histamine until it ends up in the cooking pot, freshness is not as decisive a criterion as with animal products. Even after cooking, there is not very much histamine developing, as vegetables have a low protein content.

Salicylates

Depending on the plant species, part of the plant, processing and environmental conditions, vegetables can contain much to very much salicylate. Those who react sensitively to salicylates must therefore restrict their vegetable consumption considerably, prefer vegetables low in salicylates and pay attention to a number of things when preparing them. Because vegetables are a valuable source of vitamins, minerals and other healthy plant substances, one should not limit oneself more than necessary, but stay close to one's individual tolerance limit. More information can be found on the page Mastzellerkrankungen > Begleiterkrankungen > Salicylat (in German).

Leeks, onions (genus Allium)

The genus Allium includes leeks, onions, garlic, chives and wild garlic. Experience has shown that people who react sensitively to liberators do not tolerate these vegetables very well in too large quantities. In small quantities you can use it to refine your food, but everyone has to find their own individual tolerance limit. So far, we can only speculate whether the sulphurous amino acids alliine or isoalliine may trigger the symptoms, or the allicin formed from them, which is responsible for the characteristic smell of most species.

When cooked, Allium plants are much better tolerated than when raw.

Garlic powder is better tolerated than fresh garlic, but should not contain sulphite or other preservatives.

Of the onions, two mild varieties seem to be quite well tolerated:

The White Onion (About the same size as the common onion (bulb onion) or a bit slimmer, but with a snow-white dry skin instead of a light brown one. But be careful: Unfortunately, there are several varieties of onion called "White onion" and there are several varieties of white color. Not all of them are compatible and we don't know a more specific name of the "White onion" variety we mean (produced e.g. in Italy and Australia).

The Tropea onion (deep dark red to wine red colour, elongated slender shape). "Cipolla Rossa di Tropea Calabria" is a trademark protected in the EU. Do not confuse with shallots or any other red onions.

White Onion	Tropea Onion

Unfortunately, these two varieties are not to be found in every shop. The greatest success is in small grocery stores run by foreigners from the Mediterranean region or the Balkans with an ethnic assortment (e.g. Turkish supermarkets) or perhaps at the farmers' market, gourmet supermarket or speciality shop. The white onion can also be found at Aldi Süd in Germany.

Olives

As a precaution, olives must be considered as incompatible. However, it is possible to find olives that can be well tolerated when consumed only once or occasionally (provided there is no salicylate intolerance). The following must be observed with olives:

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Mushrooms

Mushrooms consist mainly of water and proteins and are relatively perishable. Both raw and cooked, histamine can therefore develop in fungi during storage. Persons with histamine intolerance should therefore avoid reheating mushroom dishes. If they do, they should be cooled down quickly, kept cool, stored for a short time and consumed immediately after warming up.

Some species of fungi are said to be intolerant because they contain histamine liberators that release the body's own histamine. We have not yet sufficiently researched and tested which species of mushrooms this applies to. Therefore, we generally advise you to refrain completely from using fungi at the beginning of the elimination diet and to test their tolerability yourself later on. White and brown button mushrooms, for example, (also called field mushroom, common mushroom, chestnut mushroom or brown caps) are named as incompatible (Agaricus bisporus) [Medizin-Welt 2009].

On the other hand, some mushroom species are even praised as "medicinal mushrooms". For example, the triterpenes contained in the lingzhi mushroom (Reishi) are supposed to reduce the increased release of histamine under stress [MykoTroph].

Algae, algae components

Some foods contain algae. Many foods contain additives made from algae components. In our experience, algae and their components are very bad liberators (see also [Madden 2013]), but they are often difficult to recognise as such when the effect is gradual and chronic. We do not yet have an overview of whether this applies to all algae species and algae components, or whether there are compatible exceptions. We therefore recommend either avoiding them consistently or paying careful attention to slowly increasing chronic symptoms during testing. After a reaction, however, the slow subsidence of the symptoms can last from days to months. Scientific studies also show that algae products can cause chronic inflammatory diseases [Borthakur et al. 2012; Weil 2012].

Algae, especially marine algae, usually have an extremely high iodine content. Since iodine (added to table salt as potassium iodide or potassium iodate) has also attracted our attention as a strong liberator, we suspect that the iodine content of the algae (components) could be a possible reason for their poor tolerance.

Some dishes are generally known to contain algae: E.g. Sushi. Algae can also be found as a side dish in salads, soups and other dishes and in snacks, especially in Asian cuisine. Also with spice mixtures one should be vigilant (e.g. there is herbal salt with kelp).

You should always read the list of ingredients carefully to find out whether a product contains algae.

The following ingredients are algae:
Algae, kelp, seaweed, seagrass, kombu, wakame, nori, cochayuyo, sea salad (list is not exhaustive)

The following ingredient descriptions are additives from algae components:
Carrageenan, carrageenins, E407, alginate, sodium alginate E401, potassium alginate E402, ammonium alginate E403, calcium alginate E404 and propylene glycol alginate (PGA), E405, algin, alginic acid, agar agar (list is not exhaustive)

Spirulina or Arthrospira is not an alga, but a genus of cyanobacteria. In former times they were called "blue-green algae". This is why today many people still mistakenly think that spirulina is an alga. Spirulina is said to have a mast cell stabilizing, anti-allergic effect [Karkos et al. 2007].

Algae do not belong to the group of plants, but form an independent kingdom of organisms. Nevertheless, there are many food manufacturers who incorrectly label their products as "purely vegetal" or "purely plant-based" although they contain algae or even consist of 100% algae. Terms like "purely vegetal" are therefore not a reliable indication that the product is free of algae components.

Fruit

The incompatible fruits or berries listed in our food list should be avoided or replaced with well-tolerated fruits. Both fresh and frozen fruits are well suited.

Salicylates

Depending on the plant species, part of the plant, processing and environmental conditions, fruits can contain much to very much salicylates. Those who react sensitively to salicylates must therefore severely restrict their fruit consumption, prefer fruit low in salicylates and pay attention to a number of things during preparation. Because fruit is a valuable source of vitamins, minerals and other healthy plant substances, one should not limit oneself more than necessary, but stay close to one's individual tolerance limit. More information on the page Mastzellerkrankungen > Begleiterkrankungen > Salicylat (in German).

Maturity level

Be cautious with overripe fruit, rotten or crushed areas or mould. With some fruits, the content of biogenic amines can increase during ripening (e.g. bananas), while others hardly cause any problems even when overripe (e.g. persimmon, kaki).

Dried fruit

Dried fruits (preserved by slow drying) are also sufficiently well tolerated. Unfortunately, most dried fruits are sulphurised (treated with sulphur dioxide) or preserved with other incompatible preservatives or antioxidants. Therefore, always read the list of ingredients and avoid products with incompatible additives. Some dried fruits, such as apricots, can be seen from a distance whether they have been treated or not. If they still glow orange after drying, this is only possible thanks to chemistry. Unsulphurised dried apricots have a naturally unattractive brown colour but taste all the more aromatic and authentic. In some supermarkets you can find raisins, sultanas, cranberries, apricots, mango, apples and other dried fruit without any harmful additives, if you search a little.

Fructose

In addition, some sufferers (regardless of mast cell disease) have fructose intolerance or fructose malabsorption (fructose incompatibility) and must therefore severely limit their consumption of fruits and certain other foods.

It is possible that an intestine that is strongly irritated by mast cell activation also tolerates a little less fructose than normal.

Culinary herbs

Basically, all culinary herbs (kitchen herbs, pot-herbs) are well tolerated, both fresh and dried. Sage even has a soothing effect. The antibacterial ingredients contained in herbs may even slow down the formation of histamine in perishable foods and in the intestines.

Depending on the plant species, plant part, processing and environmental conditions, herbs contain high levels of salicylate (but are only consumed in small amounts). Those who react sensitively to salicylates must therefore severely restrict the consumption of herbs. More information on the page Mastzellerkrankungen > Begleiterkrankungen > Salicylat (in German).

Chives and wild garlic (Allium ursinum, also called broad-leaved garlic, wood garlic, ramsons, buckrams, bear leek or bear's garlic) in too large quantities could cause problems for individual sufferers (see above under vegetables --> leeks, onions).

Herbal salts and spice mixtures with herbs are only problematic if they contain incompatible ingredients such as algae (kelp), flavour enhancers, yeast extract, iodised salt, etc.

Many MCAD sufferers also have pollen allergies. With some pollen allergies, cross reactions with certain kitchen herbs are possible (cross allergies). In such cases one should omit those kitchen herbs to which one reacts allergically.

Seasoning, spices, aromas, condiments, flavor enhancers

Protein hydrolysate condiments

Hydrolyzed protein (or protein hydrolysate) is a frequent ingredient in bouillon, stock cubes, meat preparations, processed food, fast food, etc. Legal definition in Switzerland: "Hydrolyzed protein is the liquid, semi-solid or solid degradation product of proteins that serves to improve or enhance the taste of food". Protein-rich foodstuffs are broken down into amino acids, e.g. by prolonged boiling in a strong acid or base, or using an enzyme such as pancreatic protease. The breakdown products of proteins are amino acids, which are further degraded into biogenic amines. Therefore, it is likely that a product with protein hydrolysate can easily become incompatible. Hydrolyzed soy protein and hydrolyzed yeast are used as flavor enhancers because the hydrolysis of the protein produces free glutamic acid, which is incompatible in MCAD. The raw materials from which protein hydrolysates are made (animal, vegetable or yeast) only need to be declared if they are the most common allergens (e.g. wheat, soy). If "hydrolyzed soy protein", "hydrolyzed yeast", "protein hydrolysate", "hydrolysate", "hydrolyzed" or something similar appears on the list of ingredients, the product should always be avoided. Be aware that in the lists of ingredients there may be numerous other terms containing hydrolysates where it is not obvious. Not to be confused with spices, which are discussed in the following section.

Spices

Spices are not well tolerated because of their strong and irritating natural ingredients and because of their pungency. Since spices are only used in small quantities, they are often tolerated nevertheless. Unfortunately, spices do not have to be declared individually (in Switzerland) if their total amount is less than 2% of the product. Therefore, it is usually not possible to estimate already before purchasing how well tolerated or how spicy a finished product is. During the first few weeks of the trial elimination diet, spices should be used very cautiously or not at all. Afterwards, however, they should definitely be reintroduced on a trial basis in order to try out which spices you can tolerate and in what quantity. Spices contribute to the joy of eating despite a restrictive diet.

Hot spices

Pungent spices should generally be used sparingly or not at all. They favour the uptake of histamine by the intestine or possibly act as histamine liberators (e.g. capsaicin). Mustard (and even pure mustard seed powder of the mild variety) has also proved to be intolerable for some of those affected.

Flavorings

In the list of ingredients, behind the term "flavorings" (also: flavoring agent, flavor, aroma) can hide all kinds of things. Legal definition (Switzerland): "Natural flavouring substances as defined chemical substances with flavouring properties which are obtained by suitable physical processes (including distillation and extraction with solvents) or enzymatic or microbiological processes from substances of plant or animal origin which are used as such or processed by conventional food preparation processes (including drying, roasting and fermentation) for human consumption". Flavours, whether natural, artificial or nature-identical, are therefore sometimes tolerable, sometimes not. Flavourings occur in most products only in comparatively small, but sometimes incompatible quantities.

Yeast extract

Products containing yeast may be incompatible in some cases, but are generally well tolerated (see section on yeast pastries). Yeastextract on the other hand is clearly incompatible. Yeast extract is not yeast, but a flavour enhancer (glutamate) produced from yeast using chemical-physical methods. Yeast extract is nowadays contained in almost all bouillons, instant soups, instant meals, party snacks, sauces, spice mixtures and many other products (see declaration of ingredients) in order to give the food a stronger taste. Yeast extract is a liberator because it contains glutamate. See also the following section on flavor enhancers:

Flavor enhancer (glutamate)

The salts of the amino acid glutamic acid are generally referred to as glutamates. Due to its sensory effect glutamate is used worldwide as an important flavour enhancer. Six glutamic acid compounds are approved as additives for use in foodstuffs. These are also identified under the E numbers E 620 to E 625:

• E620 Glutamic acid
• E621 Sodium glutamate
• E622 Potassium glutamate
• E623 Calcium glutamate
• E624 Magnesium glutamate
• E625 Ammonium glutamate

Caution, glutamate is often hidden behind the following terms:
yeast extract, seasoning (condiment / vegetable seasoning / meat seasoning / soybean seasoning / liquid seasoning), flavor, lactose, fermented wheat, hydrolysate, granulated broth, stock cubes.
This is for the following reason: In order to no longer have to declare the meanwhile disliked additive glutamate as an ingredient, this flavor enhancer is no longer used in its pure form. Instead, glutamate is produced from protein-containing animal or vegetable food or waste by chemical or biochemical methods, which may then be declared as protein hydrolysate, hydrolised protein, maybe also "seasoning", "yeast extract", etc. For this purpose, for example, yeast, slaughter by-products, soya, wheat, rice or maize are boiled with hydrochloric acid and then neutralised with sodium hydroxide or enzymatically fermented.

Many sources recommend avoiding artificial flavour enhancers because of their effect as histamine liberators. The German Nutrition Society writes about this:
"Nevertheless, the use of glutamate repeatedly raised questions about tolerability. In the USA, for example, there were numerous case reports of intolerance reactions with symptoms such as tingling in the face, neck, shoulders and upper arms, headaches, nausea, weakness and heart palpitations after eating food in Chinese restaurants. As a result, the term "Chinese restaurant syndrome" became commonly complained of. Glutamate, which is used more in Chinese cuisines than elsewhere, was also mentioned as a possible cause of the complaints. However, almost all these reports come from the USA and not from Asia, where much larger amounts of glutamate are consumed. In addition, the intolerance reactions also showed up after eating in non-Chinese restaurants. Double-blind tests on people who indicated that they had Chinese restaurant syndrome did not reveal any evidence of glutamate as the cause - this was the conclusion of the scientific advisory committee JECFA (Joint Expert Committee on Food Additives) of the FAO/WHO in 1987. In 1991, the Scientific Committee on Food (SCF) of the European Union established that the Acceptable Daily Intake (ADI) for glutamate was not limited in quantity and defined as "not specified". Nevertheless, it cannot yet be excluded that there are people who are sensitive to glutamate. Here the DGE (Deutsche Gesellschaft für Ernährung e. V.) recommends to pay special attention to the labelling of foods or to avoid foods containing glutamate."[DGE 2003]

Vinegar

Fermentation vinegar belongs in principle to the foods very rich in histamine, although there are also large differences in the histamine content here: Of the fermentation vinegars, alcohol vinegar (also known as distilled vinegar, spirit vinegar, white vinegar; German: Branntweinessig) is very low in histamine and therefore well tolerated. Synthetically produced chemically pure acetic acid is even completely histamine-free. Among fruit vinegars, cider vinegar tends to be the one with the lowest histamine content. Rice vinegar could also be a reasonably tolerable alternative. Balsamic vinegar (Aceto Balsamico) is especially high in histamine.

Finding a compatible vinegar is made even more difficult, because incompatible food additives (preservatives, colorants) may be added. Therefore, keep in mind to pay attention to the list of ingredients!

After the change of diet, the first meals will taste unusually bland because the long matured and therefore particularly aromatic ingredients are missing and many spices as well as the flavor enhancers must be avoided. But this is just a matter of getting used to. Garlic (fresh or powdered) still gives the meals a strong taste, if you like it, but in too large a quantity it is also a liberator. Culinary herbs are well tolerated both fresh and dried, e.g. Herbes de Provence mixtures.

Beverages

Beverages containing histamine

Beverages produced by microbial fermentation processes (yeast fermentation or lactic acid fermentation) usually contain a lot of histamine. Examples are red wine, white wine, sparkling wine, beer (especially yeast beer), brandys, cider and other fermented fruit juices, sauerkraut juice, fermented buttermilk. Alcohol-free beers and wines also contain histamine, as these are also produced by fermentation and are only subsequently freed from alcohol. The histamine content in such beverages is subject to large fluctuations, depending on the production process, vintage, etc.

Alcoholic beverages

Alcoholic beverages play a special role in histaminosis. They are considered the main cause of the symptoms, although histamine levels tend to be lower compared to fish, raw sausages and cheese. This is for the following reasons:

• Histamine is more readily available in liquids than in solids and is therefore more readily absorbed.
• Alcohol increases the permeability of the intestinal mucosa, so that histamine reaches the bloodstream more intensively.
• alcohol and also its degradation products (acetaldehyde) inhibit the enzyme activity of diamine oxidase and thereby slow down histamine degradation.
• alcohol as so-called histamine liberator releases stored endogenous histamine and other mediators from the vesicles of certain cells.

Alcohol therefore has a fourfold effect on histaminosis and should always be restricted as much as possible. The reaction is particularly strong when histamine-rich alcoholic beverages are consumed in combination with other histamine-rich foods. A popular combination is, for example, hard cheese with red wine. [Hulsbergen 2010]

The undesirable effect of alcohol is intensified when alcoholic beverages are...

• drunk warm
• carbonated
• sugared
• drunk fast
• drunk on an empty stomach
• consumed in large quantities
• containing incompatible fruit extracts or preservatives / sulphites or dyed with artificial colouring agents (histamine liberators!)

See also: [Zimatkin and Anichtchik 1999]

Wine, sparkling wine

Wines, especially red wines, with the highest histamine levels are among the most frequent triggers of this intolerance. White wines and sparkling wines contain far less histamine and are generally more tolerable in small quantities. However, the opposite case is also observed now and then: White wines and sparkling wines tend to contain more sulphite (=histamine liberator) than red wine and can therefore trigger stronger symptoms than red wine in predisposed persons (e.g. mast cell diseases) despite a lower histamine content. Histamine in wine can develop strongly in various ways. It occurs during insufficiently controlled wine and sparkling wine production. Fresh grape must of good quality is extremely low in histamine.

The following biogenic amines are contained in wine: Ethanolamine, tryptamine, phenylethylamine, putrescin, cadaverine, histamine, tyramine, spermidine, spermine. The formation of biogenic amines can already occur during spontaneous (often undesirable) fermentation, but above all by biological acid degradation (malolactic fermentation), often by coccoidal lactic acid bacteria. Since white wines rarely (except for Swiss white wines), sparkling wines/champagnes almost never and red wines (almost) always undergo biological acid degradation, red wines generally have higher values. Wines with biological acid degradation show up to 50% higher values of organic amines.

The production method and the production hygiene have a significant influence on the content of biogenic amines in the wine: the development of histamine can be kept to a minimum through technical measures in the cellar during grape harvesting and hygienically flawless further processing (in particular alcoholic fermentation and biological acid degradation). A major role in the development of biogenic amines in wine is played by the storage of the young wine and its further development. Storage in wooden barrels or barriques leads to significantly higher histamine values in the wine. Histamine can largely be removed from the wine before bottling by a bentonite treatment. However, biogenic amines can never be completely removed.

Wines from Spain are still problematic and have high values. Wines from southern Italy have almost as high values. These are all predominantly red wines with very long barrel storage.

The basic rule for buying wine is: Prefer young wines. Do not store for long. Choose white wines WITHOUT biological acid degradation. The lower the acidity of a wine, the higher the histamine content. Unfortunately, this also applies to sweet dessert wines (high histamine levels). Inform yourself about the winery and winegrowers and what methods they are applying. Hulsbergen 2010]

For sparkling wine, fluctuations from vintage to vintage are usually relatively small. The storage time of a closed bottle under optimal storage conditions (cool, standing and protected from light) generally has no influence on the histamine content. If the bottle is stored incorrectly, the histamine content may change. [Schlumberger 2010]

Beer

In beers, the histamine values of the beer types and manufacturers fluctuate enormously. Hygiene and production methods are also crucial in beer production. In principle, top-fermented beers such as the well-known yeast-wheat beer have higher values than bottom-fermented beers, e.g. Pils.

Upper-fermented yeast forms interconnected colonies. After the brewing process they float on top of the brew and can be skimmed off. Top-fermented yeast works at temperatures between 15 and 20 degrees. E.g. wheat beer, weiss beer, Altbier (old beer).

Bottom-fermented yeast settles at the bottom of the boiler after brewing. Bottom-fermented yeast works at temperatures between 4 and 9 degrees. E.g. Pils, lager, special, spelt beer, maize beer etc. Hulsbergen 2010]

Distillates

Watch the color: Clear "schnapps" have much lower histamine values than liqueurs, sweet spirits or cask stored drinks (such as cognac, whisky). Hulsbergen 2010]

Apple juice

Apples are well tolerated. However, commercially available apple juices always contain about 10% pear juice. Because of their content of biogenic amines, pears should rather be avoided. For apple juice, therefore, test in what quantities it is tolerated. It is not easy to find out, because not the histamine content is the problem, but the content of other biogenic amines, which can indirectly lead to complaints, but do not necessarily have to, depending on what else you consume. The tolerance can also depend on whether only flawless goods or also rotten or already fermenting fruit is used.

Miscellaneous

Chocolate

Dark chocolate and other products made with cocoa (chocolate cake, chocolate ice cream) are incompatible. In particular, migraine patients often do not tolerate chocolate well. Although chocolate contains very little histamine, it contains tyramine and phenylethylamine, two biogenic amines derived from cocoa. These biogenic amines cause similar complaints to histamine-containing foods. White chocolate is much better tolerated. Carob powder also has a liberator effect and is therefore not suitable as a chocolate substitute when sensitive to liberators.

Öl, Fett

Pure oils and fats are basically free from histamine because no histamine can be produced from these substances and also because histamine is very poorly fat-soluble and would therefore remain in the aqueous phase during oil production. Even fish oil is unproblematic according to our experience. Sunflower oil is said to be more inflammatory, whereas rapeseed oil contains anti-inflammatory substances. Olive oil is neutral in this respect. When cooking you should therefore mainly use rapeseed oil. However, it is not necessary to avoid sunflower oil consistently. Also consider the heat resistance of the different types of oil.

Food additives

Numerous food additives (mainly dyes, preservatives, flavour enhancers, individual thickeners) are clearly intolerable in histaminosis (especially in mast cell diseases) or are suspected of causing intolerance reactions. They are named, for example: E210-219, E200-203, E221-228, E620-625, E100, E101, E102, E104, E120, E123, E127, E131, E132 [Schmiedel 2008]. For further information please consult our detailed foodstuffs intolerance list.

Food Supplements

The dietary supplements (multivitamin and mineral preparations, etc.) are listed on the page Therapy > Medicaments.

Where compatibility is controversial or inconsistent

For some foods and additives there is contradictory information about compatibility:

Citric acid

The additive citric acid (E330) is a very common ingredient in all kinds of foods, mostly as an acidifier. The name may cause confusion, so let us be clear here first: This is NOT about lemon juice or juice of other citrus fruit, but about a chemically pure substance, which the chemist also calls 2-Hydroxypropane-1,2,3-tricarboxylic acid. It is industrially produced in a bioreactor with the aid of moulds (Aspergillus niger) by fermenting sugary raw materials. This is usually done with molasses or maize. From lemons or other citrus fruits one could isolate also citric acid theoretically, however, this is not usual. Citric acid is also a very important metabolic product which occurs naturally in every living being and thus in almost every food. High amounts can be found particularly in fruits. In addition, this substance also occurs in mushrooms or even in milk.

On histamine websites, in books, Internet forums and in experience reports, which we receive, the general opinion is that citric acid is incompatible. Some persons say thatit provokes adverse reactions in them even in smallest quantities. On the other hand we know many (also very sensitive) persons concerned, which tolerate this ingredient also in large quantities without any problems. Therefore, we cannot yet conclusively classify E330 as compatible or incompatible. Here are a few possible explanations:

• Citric acid is a very central metabolite that occurs in all organisms. Since prehistoric times, humans have also been eating it in large quantities. This makes it unlikely that the same substance, when used as an additive, will be incompatible.
• Citric acid is produced with the aid of moulds (Aspergillus niger). In the final product, traces of mould allergens could perhaps still be contained, so that individual affected persons react to it because of a (perhaps still unrecognized) mould allergy. This would also explain why some people allegedly react to small amounts with very severe symptoms.
• Citric acid is produced by fermentation. Fermentation processes usually produce histamine and other biogenic amines. On the other hand, the citric acid is purified and the isolated end product is usually crystalline with a very high degree of purity, so that no impurities in problematic amounts would be expected. Perhaps cheap material is being adulterated here and there by saving a few cleaning steps?
• Some affected people may not even mean the additive E330 when they talk about "citric acid", but confuse it with the lemon juice substitute in plastic bottles, which is found in many households in the refrigerator. This is often a mixture of E330 and lemon juice concentrate (and therefore logically incompatible because of the lemon juice from real lemons). The contents of the bottle can also get mouldy before you have used it up, but this is difficult to see because you cannot see inside the bottle.
• Some people are highly sensitive to acids and generally tolerate acids very poorly. In some cases acid sensitivity could therefore also be a possible explanation.

Conclusion: Citric acid does not necessarily have to be incompatible. Most people will probably tolerate it without any problems. Since this additive occurs in an enormous number of products, one should not limit oneself unnecessarily, but try out whether one can tolerate such products. Citric acid can also be bought in pharmacies and drugstores in small amounts of a few grams, in order to try it out with pure high-quality citric acid (dissolved in water and diluted).

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