Am I Missing Something

Am I getting the nutrition I need, or am I missing something? It’s a question often asked by those with food intolerance and allergies. It’s also a question parents ask themselves when the kids will only eat mac & cheese and pizza.

An easy way to temper these concerns is to add supplements to our diet. On any given day, roughly half of us make this choice. Some do it with the intent of filling in dietary gaps for overall health. Others desire to prevent diseases like heart disease, osteoporosis, and cancer.

Are supplements the easy answer? I guess the answer to that is yes. Maybe a better question is whether they will accomplish what we intend.

After her Dr. Pepper phase, my mother began her day with somewhere between 15 and 20 pills – all supplements. After that, she drank a cup of hot water. Later, she might have buttered noodles, a lettuce salad topped with lemon juice, toast, and sometimes chili or pickled beets. When she continued to lose weight she couldn’t afford to lose, she began making drinks filled with protein powder.

Her diet leaned heavily on supplements to provide needed nutrition because her food intake was limited in both variety and volume. While she believed strongly in her decisions, supplements were not sufficient to support an optimum state of health.

A review of research suggests her experience is not unique. Supplements may not be as effective as we hope for preventing cancer and cardio-vascular events. And while supplementation of calcium and vitamin D can be helpful in preventing fractures to a point, in excess it can lead to harm.

So maybe the easy solution isn’t all that easy. To get the optimum benefits, you’ll need to carefully study the contents and contraindications of each supplement. Because the FDA doesn’t not have authority to review dietary supplements, this may mean you’ll have to contact manufacturers directly.

It will be prudent to read research on the interaction of dietary supplements and any prescription drugs you may take. And it will be beneficial to be up-to-date on research showing the effectiveness of supplements in many areas.

For those of us who are generally healthy but rely primarily on processed or restaurant food, it may prove to be less time consuming to make dietary changes rather than research supplements. Even if you don’t have lots of time to cook, incorporating more raw fruits and vegetables can improve vitamin and mineral intake. Choosing farm to table restaurants (make sure they are as advertised) can also improve the nutrient quality of your diet without requiring prep time.

If you are eating gluten-free, you may miss out on the vitamins and minerals used to fortify white flour products. But if you are consuming a wide variety of meat, poultry, fish, dairy, fruits, vegetables, nuts, seeds, and allowed whole grains regularly, you may not be missing any necessary nutrients.

For those whose doctors recommend supplements, don’t be afraid to ask questions to make sure you understand why and what benefits you can expect. If you are willing to make them, feel free to ask whether dietary changes could accomplish the same result. Working with your doctor, you can be an active participant in your own health plan.

When it comes to nutrition, we all want to make sure we get what our bodies require to be healthy. Dietary supplements are a tool you may or may not need. And they may or may not be effective in prevention or improvement of the condition you hope to prevent or improve.

Dietary supplements may look like the easy answer to the question, am I missing something? But when it comes to diet and health, it’s complicated.

Dig Deeper

When trying to eliminate foods that irritate, sometimes we have to dig deeper. Everything affects everything – allergies, sensitivities, disease process, gut microbiome, diet. Complex systems sometimes mean complex interactions. We want it to be simple, but sometimes it’s not. In order to be a productive member of our healthcare team, we may have to dig a little deeper and meticulously record our response to foods. 

Let’s dig a little deeper into histamine intolerance. When making food choices, it could be helpful to know that the level of histamine detected in canned fish has ranged from none detected to 657.05 mg/kg as compared to fresh fish which ranges from none detected to 36.55 mg/kg. That’s a big difference. And it partially explains why you might easily tolerate canned fish in one sitting and experience significant symptoms in another.

It can also be helpful to know that the high-end range for beer is 21.60 mg/kg and for red wine, 55 mg/kg. If you can tolerate gluten, beer (other than specialty GF) may be a better choice than red wine. 

And, of course, histamine consumption is cumulative so a meal of sausage (up to 357.7 mg/kg), sauerkraut (up to 10 mg/kg), and beer could leave you feeling miserable. Or maybe you pair sausage with spinach and red wine and end up missing your daughter’’s soccer game. Most of us want to avoid feeling miserable and missing out, right?

And yet it’s difficult to get the kind of specific information we need to make good decisions. And when you can find the information, some amounts will be listed in milligrams (mg). Others are listed in micrograms (mcg). Without moving lots of decimals around, it’s difficult to determine what indicates a high level or how one level compares with another.

In spite of growth in translational research, a grand gulf remains between research findings on diet and readily accessible, easy-to-understand, standardized dissemination of information to the general public. As patients, we’re often expected to follow guidelines that are so general (avoid fermented foods if you’re histamine intolerant) they seem off-base when we have sausage without beer and sauerkraut and still suffer.

No one is happy to follow a specialized diet. When a patient agrees to do so then experiences symptoms anyway, they are less likely to continue the regimen. They may even become less likely to comply with other doctors’ orders. 

I can talk all day about the need to dig deeper and even if you’re willing to and have unlimited time, you may find that the healthcare system is not in a place to meet you in the middle. Translational research could be that place, well-care (well-child care) could be that place, holistic medicine could be that place, integrative medicine has some potential, but right now the gaps are great in all of these areas. The crux of the problem is insufficient communication and dissemination of information. Whether this is deliberate or results from low priority, it seems to be culturally pervasive. 

I know from personal experience how frustrating that feels. I still believe that digging deeper is worth it. But I understand that the time investment may not be realistic for everyone. 

The purpose of this post is to raise awareness that a prescribed dietary regimen may be appropriate. You may be complying with the guidelines you’ve been given. And you may still have symptoms due to incomplete information with which you’ve been provided and/or which is readily available for your condition.

Before you give the plan up as futile, you may want to dig deeper. 

Not Exactly an Allergy

Even though your nose is running, your stomach churning, and your skin itching, you may be experiencing something that’s not exactly an allergy. It could be histamine intolerance.

Histamine Intolerance

Histamine intolerance, also known as enteral histaminosis, is a disorder that arises because of a body’s inability to degrade histamine due to diminished diamine oxidase (DAO) enzyme activity which leads to histamine accumulation in plasma and the appearance of adverse effects. That means when a person with histamine intolerance eats foods high in histamines (or that trigger their production) they’ll have an excess of histamine in their system just like they would if an allergic reaction triggered their body to release histamines. Unsurprisingly, the resulting symptoms are similar.


Symptoms of histamine intolerance include headache, dizziness, nasal congestion, sneezing, bloating, diarrhea, abdominal pain, nausea, itching, swelling, eczema, tachycardia, and hypotonia. The most common are gastrointestinal followed by dizziness, headaches, and palpitations, then respiratory and finally, dermatological. An Austrian study found an average of 11 symptoms per patient. That’s a lot of discomfort.

And while histamine intolerance may be causing a lot of unpleasantness, the lack of consensus for a diagnostic algorithm makes diagnosis a dicey proposition. Patients often end up seeing multiple physicians in an effort to get a diagnosis and treatment that will reduce symptoms.


The primary strategy for treating histamine intolerance is to follow a low-histamine diet. Foods to avoid include spinach, eggplant, tomatoes, fermented foods, and meat or fish that is not fresh. It is also possible for papayas, kiwis, strawberries, pineapples, and plums to trigger the release of histamine so they should be consumed with caution.

DAO supplements have been proposed as an additional treatment. In Europe, regulations authorize a DAO supplement of enteric-coated porcine kidney protein extract to be marketed as food for special medical purposes.

More to Come

Multiple symptoms in multiple systems, a condition that’s difficult to diagnose, dietary treatment – these probably sound familiar to anyone with celiac disease. And it’s possible there is a connection. DAO activity increases progressively from the duodenum to the ileum and is located mainly in the intestinal villi. What is the effect when the villi become damaged from celiac disease?

Studies showing lessened DAO enzyme concentrations in untreated celiac patients vs those on a gluten-free diet could be an indicator that there is a relationship to be explored. Other connections to IBS and non-celiac gluten/wheat sensitivity (NCGWS) have been established. But studies of histamine intolerance are relatively new. We have much to learn and many connections to make.

In the meantime, if you suspect that histamine intolerance good be causing your allergy-like symptoms, keep a food/symptom diary. This will give you a written history to share with your physician. Don’t be afraid to ask whether they have considered histamine intolerance. You are a valuable part of your medical team.

Together with your doctor, you may develop a diagnostic plan that includes some of the following: skin-prick test; histamine elimination diet; analysis of blood, urine, and stool samples. Once a diagnosis is established, dietary change can eliminate most or all of the symptoms.

While a dietary change may not be your preference, fewer symptoms will bring you relief. And relief is what most of us are looking for even if what we have is not exactly an allergy.

What Counts?

What counts? Sometimes, the simplest questions seem hard to answer. Can I tolerate a spoonful of cream sauce? If I eat one bite of gluten-filled pastry, will it damage my small intestine? Should I eat more fat to keep my blood sugar stable? Do I have to avoid all carbs? What exactly counts?

There are plenty of plate diagrams divided up in ways that should make it easy to answer some of these questions. But for every colorful chart, there is a TED Talk or expert somewhere with a conflicting point-of-view.

There are small studies that may be indicative of nothing cited as if they are gospel. There are large studies that negate earlier studies. Trying to follow the science to be your healthiest can easily become a full-time job.

Healthcare professionals are so overtaxed that they may not have time to read the newest research. That means dietary advice from a doctor can sometimes be outdated. This is one of my great frustrations!

Unfortunately, our general confusion regarding science, medical advice, and public health guidelines is playing out on Twitter in real-time now that we have a pandemic. And I’m hearing it in personal conversations as well.

So, what can you look for when determining what advice to follow?

  • Look for peer-reviewed studies that are published in reputable journals or included in the US National Library of Medicine on the NIH website.
  • Look for Randomized Control Trials if available. These have the most rigorous study design.
  • Look for rigorous studies with the largest number of research participants you can find. Larger numbers in a well-designed study will yield more reliable results than smaller ones when extended across a population.
  • Take note of who funded the study. If a drug trial is funded by a pharmaceutical company, you may want to look for additional studies funded by other sources to confirm the results.
  • Look for researchers that are respected by a wide range of scholars, physicians, and researchers.
  • Read the actual abstract of a study that’s cited in articles you read. I have found that headlines, and sometimes whole articles, often misstate the results of a study.
  • Check the credentials of Ted Talk participants. Just because an idea goes against the norm, doesn’t mean it’s wrong. It also doesn’t guarantee it’s right. The more you know about a speaker’s background, the better equipped you’ll be to make a determination on reliability.
  • Look for repeated results. If numerous studies of a particular topic find the same thing, the conclusions are more reliable than if they all have different findings.
  • Read with an open mind. We all have biases. When we can set those aside, we create a better environment for learning.
  • Trust yourself. If you see a glaring hole in a study, there may be a glaring hole in the study. Like any industry, researchers who are enmeshed in their work can have blind spots. Look for confirmation from other studies or ask an expert on Twitter.

Narrowing your research by using these criteria will help save time and give you the most reliable information available. It may still be difficult to determine what counts, but it will certainly give you a head start.