Adapted from episode 66 of The Perfect Stool podcast and edited for readability.
Heidi Turner, MS, RDN, CD is an Integrative Registered Dietitian Nutritionist at her telehealth-based private practice, FoodLogic located in Tacoma, WA. She specializes in complex health issues including SIBO, autoimmune conditions, histamine intolerance, Mast Cell Activation Syndrome and food chemical sensitivities. She spent 12 years at The Seattle Arthritis Clinic at Northwest Hospital-University of Washington where she counseled thousands of rheumatology patients on ways to reduce inflammation through dietary change and manipulation of the microbiome. She is the co-creator of the “Low Histamine Biphasic Diet” with Dr. Nirala Jacobi, and sits on the medical advisory board for the Ruscio Institute. She has guested on multiple podcasts and professional conferences discussing histamine and chemical food intolerances. Heidi earned her Master’s degree from Bastyr University in Kenmore, Washington and completed her dietetic internship at Virginia Mason Medical Center. She lives happily in the Puget Sound area of Washington State with her husband, son and devoted cats.
Lindsey:
So my readers should be pretty familiar with SIBO, which is one of our topics today, but when we last focused on it in particular was probably the episode with Nirala Jacobi in November of 2019 in Episode 17. Also had episode 36 on IBS and episode 41 with Norm Robillard. But anyway, could you just give us a brief overview of what SIBO is, and some of its common root causes.
Heidi Turner, RDN:
Oh, sure. So small intestinal bacterial overgrowth, see-bo, sibo, S I B O, or however you choose to say it, is basically a situation where there is an overgrowth of bacteria located in the small intestine. We basically should have very few bacteria in our small intestine, and the majority of the bacteria that we house should primarily be in the large intestine. So when we have too much bacteria, located in the small intestine, it can start to create a level of inflammation. And that inflammation can start to express itself in a number of different ways. We might get different symptoms that we might deem to be very like IBS, things like gas and bloating, diarrhea or constipation, sometimes heartburn, sometimes abdominal pain, really just depends upon the person and what their specific situation is. There are many potential underlying reasons why SIBO might be present. Iit is usually considered an issue of dysmotility. So we rely upon these peristaltic waves to move the contents of our food as well as the bacteria through our digestive tract. And so when that system becomes more stagnant, things aren’t moving as effectively, we can start to collect more bacteria in that space. And that can be due to a number of different causes that can be from a history of food poisoning that can actually impact something called the migrating motor complex that actually helps us to move our nerves and move those peristaltic waves. It can be related to certain medications; antibiotics can cause this. It can be from high levels of stress. I see this quite often, very high chronic stress, that can impact motility, thyroid issues, long-term proton pump inhibitor use, and then other environmental factors such as living in moldy conditions. There’s lots of different reasons that can feed into this dysregulation of the digestive tract and start to accumulate more bacteria.
Lindsey:
Thanks. So there are a couple that just come to mind too, that are more physical causes, like adhesions after surgery.
Heidi Turner, RDN:
Yep.
Lindsey:
Or Ehlers Danlos Syndrome?
Heidi Turner, RDN:
Absolutely.
Lindsey:
Yeah. And what was the other one? I was thinking about… Oh, traumatic brain injuries?
Heidi Turner, RDN:
Sure. Absolutely. Yeah. Anything that gets in the way of those neurons in the gut from really fully expressing and fully moving and communicating with each other can really get in the way. I’d also say, you’d mentioned adhesions, so that can be from say endometriosis.
Lindsey:
Right.
Heidi Turner, RDN:
So that can be from any abdominal injuries that you’ve experienced. So there’s lots of different things that can lead to those adhesions as well that block that bacteria in the area and make it something difficult to move through.
Lindsey:
Yeah, I didn’t know what an adhesion was. And I’m not sure everybody does. But I went through endometriosis. So can you just explain that briefly?
Heidi Turner, RDN:
Yeah, it’s just a basically like scar tissue that’s in our digestive tract. Well, it’s not even necessarily in the digestive tract, so it could be on the outside and impacting other organs. And so if we have a considerable amount of scar tissue, it can actually adhere to our digestive tract, which is quite large in our abdominal cavity, and so we can see those adhesions basically wrap themselves around our small intestine, especially. And so we can see that and it just creates this narrowing. Not necessarily a blockage, because that would create something different, like an actual blockage where things couldn’t get through. It’s certainly a narrowing where it’s more challenging for things to move through these very small spaces.
Heidi Turner, RDN:
Okay, great. So second topic for today is histamine intolerance. So let me ask what is histamine intolerance? And when should people suspect that they have it?
Heidi Turner, RDN:
Okay, so these run parallel sometimes. So I’ll run over the histamine intolerance. So first, before we talk about what it is, let’s just talk about what histamine is first so we’re all on the same page with what that is. So histamine is basically a chemical that our body just naturally produces. We might think of it in relation to allergies. So if we’ve been exposed to say pollen, and we get a snotty and sneezy and allergic type of thing, we take an anti-histamine. And so histamines are involved in that allergic reaction. So that’s one area where histamines show themselves, but histamine is really involved in a lot of other biochemical processes. It regulates our digestion, it helps us to build stomach acid. It is actually a neurotransmitter that regulates other neurotransmitters like serotonin. It’s involved in our sleep cycle; it helps us to wake up. It’s involved in our menstrual cycle, our circulatory system. So it’s really an incredibly important chemical that our body produces. It regulates inflammation as well. So it doesn’t just create inflammation, it also regulates inflammation. So histamine is a really, really critical compound that’s vital and important to who we are.
Lindsey:
That makes me stop and say, “Wait a second, if I’m taking an anti-histamine, that’s all my bodily systems!” Because I do that on a daily basis.
Heidi Turner, RDN:
Okay, all right, but we’re not there yet. So like in a normal average situation, we are building histamine, we’re using histamine, and then we’re breaking histamine down. And so that’s the key piece in all of this. So if we are building histamine, utilizing our histamine, and then we actually can’t break it down, and we’ll get into why that might be. And usually, it’s because we’re overwhelming our enzymatic pathways. So if we build histamine, in order for us to break it down, we need enzymes to help us do that. So we’re deficient in the two major enzymes that our body uses to break histamine down. One is called diamine oxidase or otherwise known as DAO, or Histamine N-methyltransferase, or HNMT. So if we are deficient, and usually DAO is the one that we’re thinking about more when we’re working with SIBO, just so you know. So if we’re deficient in any one of those enzymes, what can happen is we build a histamine, we can’t break the histamine down. And so we end up with a lot of a lot of circulating histamine and we have more histamine than our body can manage. That’s where we start to see problems. That’s where we start to see symptoms where there’s just an excess of histamine, that’s where we might feel more allergic, or we might feel more anxious and awake, our sleep cycles might get impacted, we might get a lot of digestive issues like heartburn or bloat or diarrhea. So anywhere where histamine regulates different areas, we might see an uptick of those symptoms. And so that’s where things become more problematic. And that is a situation of histamine dysregulation, building too much histamine, don’t have enough enzyme to break it down, I got too much circulating histamine, it’s binding to all these receptors in my body where histamine typically works and it’s agitating and aggravating and making those symptoms much more. That’s histamine dysregulation.
Lindsey:
Okay, so I’m hearing symptoms that range from allergies to digestive issues to anxiety.
Heidi Turner, RDN:
Absolutely. Yeah.
Lindsey:
So are there any of those that you could say, are very, like you’re not going to see histamine intolerance without seeing them, like an typical allergy reaction, like a runny nose or itchy eyes or things like that?
Heidi Turner, RDN:
I mean, we can have those symptoms without having histamine dysregulation. And let’s talk about what histamine intolerance is specifically, because that’s different. They’re similar, but it’s sort of a different answer to your question there. So histamine intolerance is a situation. So this is going to bring in that SIBO here for a second. So let’s step back. When our gut produces a lot of that diamine oxidase, that DAO, and we use up a lot of that to help to break down the histamine that comes in from our food supply. So we have all of these foods that contain histamine and typically these are foods that are usually aged or fermented, like sauerkraut or wine or aged meats or foods that have been spoiled or hanging around for long periods of time, or just other foods that contain natural amounts of histamine or biogenic amines like avocado or spinach or tomatoes. When we eat those foods, our gut produces all of that diamine oxidase to help us break down those histamines that are in our foods. And if we don’t have adequate amounts of diamine oxidase, then what’s going to happen is the histamine that’s in the food is going to be absorbed into our bloodstream and create more systemic histamine. And it can also exert just a more inflammatory effect in the gut. So if we don’t have adequate amounts of that DAO, it’s going to cause a histamine intolerance, and that’s where we just don’t tolerate the histamines that are in our foods. So there’s the histamine intolerance, and then there’s the histamine dysregulation. I’ve got too much histamine. I’m building too much histamine. My enzymatic system can’t keep up with it. And I’m eating too much histamine. And my enzymatic system can’t do much with that. That’s the difference. Histamine intolerance versus histamine dysregulation.
Lindsey:
Okay, so is it essentially a spectrum and one is more extreme?
Heidi Turner, RDN:
Oh, not necessarily. If you have histamine issues and back to your question, it’s like, if you’re super allergic and snotty, sneezy, you could have other issues going on and feeding into that. It doesn’t necessarily mean you’re histamine intolerant. However, if you do have a history, I mean dysregulation going on, and your body just isn’t making adequate amounts of enzymes to help you break it down, I think looking at other things that could be feeding into that, like gut bacteria, histamines and the foods. That’s where we want to start focusing in on other areas, because it’s possible we could help to reduce some of the symptoms that we experience from allergies by looking elsewhere at other places where the body produces too much histamine.
Lindsey:
Got it. Okay.
Heidi Turner, RDN:
That makes sense.
Lindsey:
Yeah. So how can SIBO lead to histamine intolerance?
Heidi Turner, RDN:
Yeah, exactly. So bacterial overgrowth is a situation, there’s actually a couple of reasons. So you know, the bacteria, if we have too many bacteria in our digestive tract, it’s inherently creating a lot of inflammation. So they produce something called lipopolysaccharides. Those lipopolysaccharides can induce more mast cell release in the digestive tract. And those mast cells contain a lot of histamine, and that triggers more reactivity. So if we have a lot of inflammation from bacterial overgrowth, then we’re using up a lot of that diamine oxidase that our gut is producing. So we’re using a lot of that up. So if we’re using up all that DAO and we take in a lot of dietary histamine, you might not have enough DAO available for that dietary histamine. So that’s the first way. The second way is that we know that in the more recent research, the type of bacteria that are often implicated in SIBO are histamine producing bacteria, so things like E. coli, or Klebsiella. Both of those are implicated as star actors in SIBO. And both of those produce a lot of histamine. So we have an overgrowth of bacteria in our gut that produce a lot of histamine. That too is going to use up all that diamine oxidase. And it’s going to get in the way of our histamine tolerance.
Lindsey:
Oh, okay. That’s interesting. So how can you address histamine intolerance through your diet?
Heidi Turner, RDN:
Right. So there’s a lot of different ways you can do that. And I think we should probably bring the SIBO into this as well…
Lindsey:
Because you want to get rid of the SIBO.
Heidi Turner, RDN:
You want to get rid of the SIBO, right? Because I just want to make sure that we all understand that whenever you have any dietary intolerance, it’s usually secondary to something else.
Lindsey:
Right.
Heidi Turner, RDN:
Some other dysregulation going on, so we want to make sure that it’s not just about, we’ll take all of these hundreds of foods out of your diet, and then you’ll be fine. Because you might take those foods out of the diet, and you might actually feel a lot better. But that’s not really the answer, because staying on a highly restricted diet for a long period of time is very uncomfortable, and socially isolating, and all of those things that can come with dietary restriction. So let’s just make sure that that’s said before we jump into what do you do with a diet. So before we get there, there’s a number of different things that you can do with a diet. But let’s bring the SIBO back onto the table. Because ideally, if we can treat the SIBO effectively, then we can reduce a lot of that intestinal inflammation, which then buys back a lot of your diamine oxidase, in which case, we don’t necessarily have to eliminate too many foods from the diet.
So ideally, in a perfect world, we’re going to be able to manage that SIBO, reduce the intestinal inflammation and we don’t have an issue from a histamine perspective. So that alone, we just want to make sure that that is covered. Now, let’s say you need to do a little bit more with the diet, though, because often times, when we are working with SIBO, what’s generally indicated in a SIBO diet is more of a low FODMAP type of diet. So oftentimes, we will do antimicrobial, and then once we’re finished with the antimicrobials or the antibiotics, we will usually follow that up with a low fermentable diet. And so these foods aren’t necessarily high in histamine. But we do know that a low FODMAP diet can actually reduce intestinal inflammation. And again, you reduce intestinal inflammation, you can build a little bit more diamine oxidase back. And so that can actually help you with your digestion of higher histamine foods. So sometimes, just by reducing things, if you’re going to work with SIBO, sometimes by reducing the bacterial concentration, and then actually incorporating a low FODMAP diet, we can actually see a better regulation of histamines in the diet. And we don’t really have to do too much more than that. So that’s one of the first things we can do with our food or just see how it goes for us. That’s number one.
Now, let’s say that doesn’t work for you. It doesn’t work for everybody. Let’s say hey, I cannot kick the SIBO and I’m doing this low FODMAP diet and it does absolutely nothing for me or it’s actually making things worse. So a low FODMAP diet, which is low in Brussels sprouts and cauliflower and onions and garlic and things like that, is inherently high in histamine foods. So, in some cases, if we’ve got really significant histamine dysregulation in the gut and even though we’re doing all the things we know to do to combat our SIBO, if we’re eating a lot of high histamine foods, because we’re doing all of these practices, what can happen is we don’t have any diamine oxidase. And so we’re going to end up with more intestinal inflammation because of it. So then what we can actually do is go on a low histamine diet. And that’s where we really pull out a lot of these aged foods, the avocados and spinach, and tomatoes and all sorts of different fermented foods that we might be eating because we’re trying to feed our microbiome and bone broths all these different things that are aged or fermented or old, can actually be impacting us adversely. And so sometimes we need to take those histamines out to give the gut a chance to heal and not just reduce symptoms that we’re experiencing, like abdominal pain, or bloat or things like that, but also just give the gut a chance to heal. So yeah, so these are all just different things. I’ll just say, there’s a lot of different dietary strategies that you can make that can impact or actually reduce your histamine intolerance that don’t necessarily just limit you to like taking all the histamines out of your diet. So even like a paleo type of diet, like a low starch diet, or a low sugar diet can actually improve your diamine oxidase and reduce your histamine intolerance as well. So there’s lots of different ways that you can approach the diet. Reducing histamines is one of them.
Lindsey:
And they serve to do that because they reduce inflammation.
Heidi Turner, RDN:
Yeah, absolutely. Any time you’re reducing inflammation, you’re allowing the body to support more diamine oxidase production. That’s the key thing. That’s your key guy, diamine oxidase.
Lindsey:
Yeah. So what I’m hearing is that you’re typically dealing with the SIBO first, and then you’re putting people onto the low FODMAP diet, for example.
Heidi Turner, RDN:
Yeah, absolutely. I really try to spare the diet. I’m a dietitian. And I try not to take foods out of people’s diets, because it’s a challenge, especially things like FODMAPs, things like histamines. It’s not just one food. It’s not just gluten or dairy or starch. It’s like there’s 100 different histamine foods that we’re when we’re working with the lists, and there’s 100 different FODMAP foods when we’re working with the lists. And so it can get really challenging really fast. And so I really try to listen to my clients in terms of what’s possible. Ideally, we’re going to be making some dietary modifications in the short term. And I think that that’s the most important thing for us to highlight, if you’re going to be making any dietary modification, it is for a very short period of time to manage symptoms, and to support healing, right. It’s not to stay on for the rest of your life. Because if you have to, if you have to take FODMAPs out or you have to take histamines out and you can’t get them back in, there’s something we haven’t fixed.
Lindsey:
Yeah.
Heidi Turner, RDN:
There’s something else that needs to be done. So, from my perspective, back to your question, is that, do you do work with the SIBO first? Sure, absolutely. It’s like, what can we do to manage that? Because if that’s all we need to get at in order to reduce the intestinal inflammation, then how much more do we need to do from a dietary perspective from there?
Lindsey:
So how long would it, and do you tend to use herbal protocols for SIBO or Rifaximin, or…
Heidi Turner, RDN:
I’ve used it all. So yeah, so you know, I’m a dietician. So I don’t prescribe medication, but I usually do work with other practitioners who do so. I have worked with antimicrobials. I’ve worked with Rifaximin and neomycin or metronidazole. I’ve worked with elemental diets. And then also every other possible dietary strategy you could possibly imagine. We’ve used fasting, you know, there’s lots of different strategies to manage the SIBO.
Lindsey:
Right.
Heidi Turner, RDN:
It’s just a question of, there’s a lot where do you start? It’s a question of tolerance. Maybe the person might not tolerate herbal antimicrobials? Well, it’s a question of expense. Rifaximin can be $1,000 investment.right?
Lindsey:
Right. Yeah, it’s one of those things that has got to be covered by insurance. There’s no logical reason to take that over herbals.
Heidi Turner, RDN:
That’s exactly right. And so if cost is an issue, then your herbals are going to be a better option for you. Elemental diets are also quite expensive. So you always have to just navigate someone’s personal bent, their personal belief structure. Some are just like, I don’t want to do herbals. I’m not going to fast for two weeks. So I’m going to go and get my Rifaximin and I’ll spend my $700 or $1,000. And that’s what I’m going to do versus the next person who might be “No, I’m not taking antibiotics for nothing”. And I’m going to go the antimicrobial route, right so really I do a lot of counseling around it when really trying to figure out what’s going to be the best strategy and working with their SIBO. And then also what’s going to be the best strategy in working with their diet. Because having done this for a long period of time, there’s never one road for one person, everybody is different. And I think that’s the challenge in the US. Practitioners that work with SIBO, or work with dietary restrictions, and not only is it challenging for everyone, but everyone’s so different, right? Everyone’s so different. So you just have to have a lot of tools at your disposal, rather, and then help your client make the right choice. Weigh them in the right direction.
Lindsey:
Right. So assuming a typical client is doing an antimicrobial regime of some sort, be it Rifaximin or herbals. I’m wondering how long that typically lasts, and then how long you would typically put them onto, say a low FODMAP diet? Or are you using the biphasic diet? And maybe you can just explain that a little bit?
Heidi Turner, RDN:
Oh, wow. That’s a big question. That’s okay. So it depends upon the person, depends upon their test results as well, their breath test results and how strong the SIBO is. It is like, what gases are we working with? If we’re borderline SIBO, then we might place them on a protocol for a shorter period of time before checking back in. If these gases are quite high, or methanogenic overgrowth, then it might take a little while longer and really depends upon the person and how they’re doing and how they’re tolerating everything as well. So it’s going to take, it could take anywhere from a month at best to several months. At the very worst, or the very longest, it could take several years, it really just depends upon the person and how they’re responding. So as far as treatment goes, it just depends. Unfortunately, I can’t give you like a, because everybody’s so different, give you like one that’s going to take this long, so it can be a challenging thing.
The diet I try to make for as short a period of time as possible with FODMAPs. I’ll usually keep a little bit of FODMAP in during the actual treatments. Allow the bacteria to feed. They love to feed on those FODMAPs and then once they’re finished with their antibiotics or antimicrobials, I will then remove those FODMAPs for a period of anywhere from two to four weeks, sometimes six weeks depending upon how long this is taking, I might just use a standard FODMAP diet. There’s lots of different diets out there. There’s Nirala Jacobi, she has the Bi-Phasic Diet, which I think is terrific. Allison Siebecker has more of a specific carbohydrates, low FODMAP diet where you take out both FODMAPs and starches as well. I think you’ve had Norm Robillard on [his Fast Tract Diet]. There’s lots of different types of diets. Cedar Sinai has a different type of diet as well. And then still, Dr. Jacobi and I also developed a low histamine, low FODMAP diet. And so for those who are doing a little bit better on low FODMAP, but we really do feel like there’s a histamine intolerance, that’s pretty severe. And we might place them on that one as well, which is quite restrictive. And even though I helped co-create them, I’m not a big fan of it, because it’s so restrictive, but it can be quite effective if we’re really, really, really inflamed, and we just can’t get that fire out. In which case, again, back to your question. It might be anywhere generally from two to six weeks. And again, if I have to go longer than that, then something else is going on. So I got to keep looking: what’s driving the SIBO, what’s driving the intestinal inflammation, what’s driving the histamine production. You always have to keep digging more and more if you must rely on dietary elimination to be asymptomatic.
Lindsey:
Right. And is there with low FODMAPs there’s a reintroduction. That’s supposed to be category by category, but with histamines is there categoric reintroductions, or how does one go back into reintroducing them?
Heidi Turner, RDN:
So I guess my short answer to your question is no, there isn’t really any formal introduction, because it is a threshold issue. It can be with FODMAPs as well. But you can also have certain tolerances to different categories of FODMAPs and not to others, whereas histamines, it’s like a threshold, like how much histamine do I tolerate in a given day or even a given week? In which case the question is how much diamine oxidase do I have available? So what I usually like to start with is keep out the foods that are really high histamine like wine or beer or high fermented foods. I’ll usually keep those guys out for a while because they’re going to use up a lot of space. They’re going to use up a lot of DAO. So I like to maybe start with more of the vegetables or the fruits that they might be missing or nuts or things like that they might be missing. And we’ll just start first with like: What do you miss the most? And you know, you miss your avocado? Do you miss a little tomato? And you know, they come up with the answer pretty quickly. So if there’s something that they’ve really dialed down on, then I might introduce those in first. I’m always a little bit judicious with tomatoes to start, because they’re not only high in histamine, they’re high in a lot like acids and things like that, that can be just irritating to the system. So I usually don’t start there but I’ll usually start with maybe a little spinach, maybe a little avocado and just get a sense of what their bodies can tolerate. And then we just slowly build from there. And if they reach a threshold at a certain point where they start to get a little bit more reactive, we’ll keep those histamines in because we know that we’ve got some level of tolerance, and then we’ll just stay below a threshold while we continue to heal the gut.
Lindsey:
Okay, so I know that there are foods that have histamine versus histamine liberating foods. Can you talk a little bit about that?
Heidi Turner, RDN:
Yeah, sure. So yes, there’s foods that contain histamine and those are usually the ones that have been fermented by bacteria like our sauerkraut or kimchi or wine or things like that. So those are the ones that are particularly high in histamine specifically, but histamine is under an umbrella of a category of chemicals called biogenic amines, and there are a number of them things like tyramine, putrescine, cadaverine, spermine, spermidine. There’s lots of different types and histamine is one of them and so most of these actually will use up diamine oxidase; they require diamine oxidase in order to get broken down. So these foods, things like oh let’s say banana isn’t necessarily high in histamine but it is high in other biogenic amines so if we’re eating the banana sure we’re not putting in more histamine but we are putting in more of the I believe it’s cadaverine in the banana, I could be wrong perhaps. So we’re putting more of that biogenic amine in and it’s using up DAO. If anything is using our DAO, it’s a problem because we do bring in those other high histamine foods. It’s looking for the DAO as well and so in order to break down, there’s lots of foods that have this ability to use up diamine oxidase; those are your histamine liberators also known as biogenic amines.
Lindsey:
That’s interesting. So if you were really careful about just the foods that actually have histamine, then you probably could be okay with eating the other ones.
Heidi Turner, RDN:
Yep, you got it? Absolutely. And sometimes we’ll just do that. So if I see the taking all of these histamine foods out and/or histamine liberators because most of the lists that you find online, and there’s like 30 different lists, they all say different things.
Lindsey:
Yeah.
Heidi Turner, RDN:
Maddening, but what they can all agree upon are the foods that are high in histamine like no one’s going to say that sauerkraut is low in histamine. No one’s going to say that wine is low in histamine. You know, it’s all of those things, so fermented, aged foods are all high in histamine. Where it gets a little murky is in the biogenic amines, but the majority of these lists contain all of them. So if I’m working with someone, and I suspect they’ve got a histamine issue, and I see that they’re drinking bone broth, and they’re taking in sauerkraut, and they’re drinking wine, and they’re eating charcuterie every night and smoked salmon every night and canned tuna all the time, then I’m going to start to think, you know, do we need to take out all of these foods, or is it enough just to dial it down? Let’s make sure your meats are as fresh as possible. Let’s lay off the sauerkraut. And sometimes just making those shifts is enough to reduce their symptoms to reduce that histamine intolerance. And then we didn’t have to take out all of the biogenic amines.
Lindsey:
Okay, so the diet that you developed, that’s not the same as the Bi-Phasic Diet.
Heidi Turner, RDN:
No, so the Bi-Phasic Diet was developed by Dr. Nirala Jacobi in Australia, right? And so that’s more like straight up SIBO.
Lindsey:
Okay.
Heidi Turner, RDN:
Right. You incorporate that, you treat the SIBO. So it’s very low FODMAP, low fermentable. Basically, it’s a low fermentable diet. When we came together, what we did is recognize that when you’re doing a low fermentable diet, you’re just naturally increasing the level of histamine that’s in there. So like tomato is low fermentable, but it’s incredibly high histamine. Spinach is low fermentable, but it’s incredibly high histamine, in biogenic amines. So what we looked to do was to acknowledge that for those who have both things going on, there’s so much intestinal inflammation going on that they’re not tolerating fermentable or fermented foods. Let’s come together and really give them something where the gut can completely calm for a period of time. And then start going through an introduction process. So it is a bi-phasic diet. It’s just it’s the Low Histamine, Low Fermentable Bi-Phasic Diet.
Lindsey:
Okay.
Heidi Turner, RDN:
And so it takes off Phase one, Phase two. Exactly. You got it.
Lindsey:
And they can find that on your website or…
Heidi Turner, RDN:
On my website and on Dr. Jacobi’s websites, both of us have it there.
Lindsey:
Okay. So, say somebody begins treatment with antimicrobials. And they have an immediate bad reaction. What might it look like if it’s related to histamines, as opposed to say, be a Herxheimer reaction?
Heidi Turner, RDN:
Well, if it’s a Herxheimer reaction, because they look really similar. Herxheimer reaction, you know, it can be pain, it can be fatigue, and Herxheimer is when you’re going through a level of die off, you’re killing off a lot of stuff. It’s all going through your liver, your liver is having a hard time catching up, your body’s having just a really, it’s going through detoxification, basically, that’s what a Herxheimer reaction is. I typically will see Herxheimer reactions not last that long. So usually, if it’s a Herxheimer reaction, you’re going to see symptoms start to increase, usually within like maybe two to four days, they’ll intensify and then typically after like a week or more, we’ll start to see things calmed down a little bit. So that would be more of your typical arch of a Herxheimer reaction, they can go longer, certainly, depending on how much bacteria you have to kill off. I might put in something to help support the liver help to reduce inflammation, if it is a Herxheimer reaction, I might put in a little N-acetylcysteine, I might put in a little vitamin C, I might try to put some things in there. Even glutamine, if you know, we just need to calm some inflammation. So I might put some things in there and see if that works and then if it does, then we’re likely working with a Herxheimer issue. If it’s a histamine reaction, which can also be a part of that whole, in that soup. But if it’s just a reaction to the actual antimicrobial, I don’t see it abating. I see it happening quickly, usually within the first day, because the body is going into an immediate reaction. And then I just don’t see it fading. So I will often pull back and maybe start a lot more slowly and see if we can gather a little tolerance with time. But that’s usually the difference if there’s just no tolerance at all. And my clients will let me know. It’s very common with things like oregano or Berberine, which are pretty intense antimicrobials, but we use them all the time for SIBO. And they just know, I cannot do this, there’s absolutely no way I’m going to be able to do this, then there’s lots of other antimicrobials we can use. And I’ll just shift over to different things and see if there’s better tolerance. And if there is then I know that that was probably a histamine reaction, inflammatory reaction that they were having to the antimicrobial itself, versus Herxheimer.
Lindsey:
And so are you saying that Oregano and Berberine in particular have histamine in them?
Heidi Turner, RDN:
No, they don’t. It’s just that they’re fairly . . . Remember, we’re always working with a level of intestinal inflammation. So if you’re someone that, when you put in an antimicrobial like berberine or oregano, they’re pretty caustic on that gut lining. And if your gut’s just like, I can’t even do that. I can’t do FODMAPs. I can’t do histamines. I got all this bacteria in here. It’s just too much on my system, that it’s more than that. No, they are not necessarily high in histamine.
Lindsey:
Okay, so the histamine reaction that’s coming with them, then is inflammatory. Okay. Got it. So once people heal their SIBO, are you seeing this histamine intolerance tend to go away?
Heidi Turner, RDN:
Yeah, often, in most cases, I would say if it’s just related to the SIBO, if their histamine intolerance is just related to the SIBO. And you’re able to manage the SIBO and then get in there with some supportive healing strategies after you’ve cleared out the bacteria. And we helped to regain that microbiome a little bit more. Yeah, absolutely. Because the histamine intolerance should not be a forever thing. It is really just dependent upon the immune system dysregulation in the gut. So if it doesn’t go away, and I see this sometimes where we have SIBO, we have histamine intolerance. We treat the SIBO. SIBO has gone with histamine intolerance is still there, then it’s a question of like, what else is going on?
Lindsey:
What else might be going on? What are the other possibilities?
Heidi Turner, RDN:
Well, I mean, you can just have general dysbiosis. So you can have fungal overgrowth or yeast overgrowth that wasn’t managed, particularly if you did just antibiotics.
Heidi Turner, RDN:
Right.
Heidi Turner, RDN:
You can have other types of probably H Pylori, you could have other problem actors in the colon like you could have other things going on in the gut that are problematic. You could be massively stressed out and I know that that’s going around. So if we have considerable amounts of stress going on, and we’re really consistently off, that really sends a signal to the gut that all is not well. And we know that there’s a strong correlation between really high chronic stress levels and not just dysbiosis, but SIBO, as well as mast cell activation of the gut. So you know, we always have to be thinking about our hormones. Some women who are estrogen dominant, or even men who are estrogen dominant, that can trigger more histamine production in the body. Your environment, if you are eating pretty a highly processed diet, or exposed to a lot of different chemicals or exposed to mold, all of these things can impact how much histamine your body produces. So we always have to be thinking about other players that could feed into why your body is making a lot of histamine and using up all of those enzymes that are necessary to break it down. Yeah, so start with SIBO. Hopefully that’s it, but if it’s not, okay, what else is that?
Lindsey:
Right. Now, you mentioned mast cell activation syndrome. How does this differ from histamine intolerance?
Heidi Turner, RDN:
Well, histamine intolerance is just I have diamine oxidase deficiency, and I can’t tolerate the histamines in my food. Okay. And so that’s histamine intolerance. And it’s on the same spectrum as mast cell activation. But mast cell activation is a little different. It’s, you know, the mast cells are these vesicles that carry histamine. We store most of the histamine that we produce in mast cells. We store it in different parts of the body as well, different cells in the body. But we really do store the majority of our histamine in mast cells. And mast cells are the ones that regulate that immune system reactivity. So we have mast cells in our gut, we have mast cells basically in nearly every area of the body. So they’re there to protect us, they’re the ones that basically get stimulated. If we do have an allergic reaction: we have an allergy to peanuts, or to pollen or something like that, we’re going to get a mast cell activation, and that’s going to secrete histamine as well as other inflammatory mediators throughout the body. We also have those mast cells that do line the gut. And so oftentimes, when we do have inflammation going on, from dysbiosis, we can see a mast cell activation. So the mast cells are in this constant state of release, degranulation, release, degranulation, and they’re secreting histamine into the body. And those mast cells can respond to stress levels, they can respond to environmental, they can respond to allergies, they can respond to any number of different activators, sometimes real, like peanut allergy, and sometimes benign, like smells or tastes in the mouth. We can see those mast cells become more susceptible to benign stimulation, and all of a sudden, we’ve got the mast cells exploding all the time and releasing histamine all the time. That’s mast cell activation. That’s very different on the same spectrum, because we’re working with histamine. But on a much more serious note, I would say.
Lindsey:
So in terms of knowing that someone has this, is there any testing they can do?
Heidi Turner, RDN:
For histamine intolerance or for mass cell activation?
Lindsey:
Both.
Heidi Turner, RDN:
So histamine intolerance? I mean, yeah, you could, if you didn’t want to take all the histamines out of the diet, you could certainly, there are a few labs that will just measure your diamine oxidase production versus the amount of histamine that is in your blood. So if you’re building a lot of histamine, you don’t have a lot of DAO, then you can extrapolate from that. I never use those. I usually just do the elimination because I find it to be the easiest thing. If I take the histamines out, how do I feel if I add them back in? How do I feel? And so that I think is good enough without having to spend a lot of money on testing. Mast cell activation is very different. You’re really looking for all of the different mediators that are released by those mast cells. And so one is histamine, but really, they’re looking at other mediators as well. Things like tryptase prostaglandins, PGD-2, PGF-2, chromogranin A, we’re sort of looking at all the different kinds of heparin, you might just look to see if there’s an elevation of those many mediators that mast cells release into the blood that would indicate that there’s some activation going on.
Lindsey:
Is dealing with mast cell activation similar to dealing with histamine intolerance?
Heidi Turner, RDN:
Sometimes, yes, it is. Not everybody who has mast cell activation has histamine intolerance. So some people who have mast cell issues, they can tolerate, their gut is making plenty of diamine oxidase, which means they can eat as many histamines as they want. It’s not going to feed into the systemic histamine that they’re producing. I’d say that that can happen. A lot of people with mast cell activation, do have histamine intolerance. Oftentimes, it’s a good place to start. Take the histamines out, see if it helps. And you can take it from there. Mass cell activation and dealing with that, it’s a different protocol because first of all, if your mast cells are leaky and they are exploding all the time, then you’ve got to get that under control. And so you really need to – so stabilization becomes the first thing that you do. And stabilization can come from dietary elimination. It can come from different medications like over the counter: histamine blockers like Allegra or Zyrtec, H1 blockers, or H2 blockers like famotidine. So we can bring those in to see if we can stabilize, and then mast cell stabilizing medications like Ketotifen or cromolyn sodium. There’s lots of different medications that we can use just to stabilize those mast cells from just telling them to just chill out, so that we can get a sense of what’s going on, what’s our underlying cause, what’s driving this mast cell activation, because it isn’t just unto itself. There’s always going to be something that’s driving that mast cell activation.
But stabilization is important to get the person through the day because it is a miserable condition. And so the more that we can just help to calm the system, calm the nervous system, calm people down, it’s really very beneficial. We can also use supplementation as well for that. We can use quercetin, we can use vitamin B6, we can use vitamin C, we can use zinc, we can use lots of different things that help to build diamine oxidase or help to stabilize mast cells. So we can do a lot to calm that mast cell activation. And once we’ve stabilized as best as we possibly can, through medication, diet and supplementation, then we start to look at, alright, what’s driving the situation? Does this person have SIBO? Does this person have fungal overgrowth? Has this person been exposed to mold? Is this an environmental issue? Like, is this a trauma that they’ve experienced? You know, what are all the pieces? Is this high levels of antibiotic use? And that has led to severe dysbiosis? Often it is a combination of all of those things. And it’s a question of how do we address and treat?
Lindsey:
Got it? Okay, so obviously, there’s some complexity here.
Heidi Turner, RDN:
Super complex.
Lindsey:
So I’m not going to go too deep into mast stuff. That’s a topic for another day.
Heidi Turner, RDN:
Yeah, as you see, like SIBO and histamine intolerance are actually a little bit more, I would simple is the wrong word. They’re just a little bit more clear.
Lindsey:
Yeah. Yeah.
Heidi Turner, RDN:
In terms of how to manage mast cell activation is its own beast that we have to take on.
Lindsey:
That might be a topic for a whole other podcast.
Heidi Turner, RDN:
Right.
Lindsey:
Okay. So anything I haven’t asked about that, that one should know about this?
Heidi Turner, RDN:
Let me think. Well, yeah, I’d say that for the at home person who’s dealing with their histamine intolerance, these are just some things that you can work with. There’s… okay, so let’s have a bacterial overgrowth. You want to work with a practitioner who really understands SIBO. I think that’s the first most important thing that someone who who’s dealt with hundreds or 1000s of SIBO cases can really help you to navigate. Really, really important. So that’s the first thing. If you do have a histamine intolerance issue and are looking for, let’s just talk about the symptoms that you might experience because SIBO can be gas and bloating, constipation, and diarrhea and things like that, and so can histamine intolerance, but if you’re experiencing a lot of GI stuff, and you have SIBO, but you’re also experiencing other symptoms, and those symptoms can be more those allergy type of symptoms like itchy skin or eyes or sneezy or sore throat or congestion, or you’re just really anxious. It causes a lot of anxiety, headaches, sometimes dizziness, temperature regulation issues, insomnia, tachycardia, that fast heartbeat or blood pressure issues or temperature issues. And you could have one of these things you could have all of those things, just depends upon the person. If you are having gut stuff, but you’re also having these other things start thinking about histamines.
And I also put it for the long COVID person who’s still experiencing a lot of symptoms after their COVID diagnosis. And you know, after they’ve recovered, if they’re having a lot of those issues, we’re seeing a lot of mast cell activation, but also histamine issues with that population. So if you’re experiencing all of that, to consider doing a low histamine diet and just see how it feels. And then you know, there’s some supplementation that you can do for yourself to help support your diamine oxidase production. I always start with vitamin B6 – first place I always start. Vitamin C as well, zinc and copper. Those are all things that are really helpful in terms of helping you to build more diamine oxidase and then help to reduce histamine in the body, things like quercetin or other bioflavonoids like luteolin or lutein, stinging nettles, these can all be really beneficial to you and again, it’s just symptom management, but they can just help to abate some of the symptoms that you experienced.
Lindsey:
I’m guessing there’s probably some products that put together all these things in one…
Heidi Turner, RDN:
That’s right, absolutely.
Lindsey:
What are some of those?
Heidi Turner, RDN:
One that I like and it depends, sometimes I’ll just start with one thing, and then see how you do. If you’re super sensitive, I’ll just go with single ingredients. But if you’re not, you can tolerate all those things. There’s one called Aller-All from Protocol for Life Balance (find in my Fullscript Dispensary*), and it has all those things in it, which I so appreciate. So that one I use quite a bit, and then the last thing I’ll say is your microbiome, that there are bacteria that produce histamine in our gut. There are bacteria that break down histamine in our gut. And so if you’re going to be working with safe probiotics, you really want to work with those that contain bacteria that help you to break histamine down, that can be really beneficial and can also improve your tolerance to probiotics if you don’t typically tolerate and if we can use names, things like Vitanica has a great one called Flora Symmetry (find in Fullscript*). And another one from Seeking Health is called HistaminX and Probiota HistaminX Probiotic (find in Fullscript*) and another one from Custom Probiotics – D Lactate Free Probiotic Powder. So these are some of the ones that I might use just to help to regulate that histamine in the gut a little bit more. Just be aware that if you don’t tolerate probiotics well, be aware that there are certain strains that do produce histamine that are found in a lot of these formulations. And if you’re super sensitive, you might just react to those. So do start with some of the ones that are more specific to histamine reduction. And then you can always expand out from there as your gut heals, and starts to tolerate more.
Lindsey:
Got it? Where can people find you? And are you practicing virtually or in person?
Heidi Turner, RDN:
Yes, I’m not practicing in person. I am practicing virtually. You can find me at foodlogic.org. And right now, I’m a little limited in terms of my availability, but you never know. You never know. I am in the process of creating classes that help to educate people on all of this. So check back frequently. I’m in production now. And so that can just give you some good useful tips on how to move forward with these conditions.
If you’re suffering with SIBO or any other gut issue, you’re welcome to set up a free, 30-minute breakthrough session with me (Lindsey). We’ll talk about what you’ve been going through and I’ll tell you about my gut health coaching 5-appointment program in which I recommend lab tests, educate you on what the results mean and the protocols used by doctors to fix the problems revealed. Or if you’re ready to jump in right away or can just afford one appointment at a time, you can set up an 1-hour consultation with me.
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