Can individuals with histamine intolerance consume naturally cultured bread on a low histamine diet?

Naturally Cultured Bread and Low Histamine Diet

Naturally cultured bread should be avoided on a low histamine diet as fermented foods are unanimously excluded in evidence-based histamine intolerance management guidelines. 1

Understanding Histamine Intolerance

Histamine intolerance results from an imbalance between accumulated histamine and the body's capacity for histamine degradation. This condition occurs when diamine oxidase (DAO), the main enzyme responsible for metabolizing ingested histamine, has reduced activity, leading to histamine excess that can cause numerous symptoms mimicking allergic reactions 2.

Key differences between food allergy and histamine intolerance:

• Food allergy: An immune-mediated response most commonly associated with IgE antibodies 3
• Histamine intolerance: A non-immunological response related to impaired histamine metabolism 4

Foods to Avoid on a Low Histamine Diet

Definitely Avoid:

• All fermented foods - unanimously excluded in all low-histamine diets 1, which includes:
  • Naturally cultured/fermented bread
  • Aged cheeses
  • Fermented alcoholic beverages
  • Fermented vegetables (sauerkraut, kimchi)
  • Vinegar-containing foods

Rationale for Avoiding Fermented Bread

Fermentation processes naturally increase histamine content in foods. The fermentation involved in making naturally cultured bread (using sourdough starters or other fermentation methods) produces histamine that can trigger symptoms in sensitive individuals.

Diagnostic Considerations

Diagnosing histamine intolerance requires a complex, time-demanding multidisciplinary approach 4. Recent research shows that single-blind placebo-controlled histamine challenges disprove histamine intolerance in the majority of patients with suspected HIT, with placebo reactions being frequent 5.

Management Approach

1. Dietary modification: A low-histamine diet is considered the gold standard for treatment 4

   • Complete avoidance of fermented foods, including naturally cultured bread
   • Consider regular commercially produced bread made with commercial yeast as an alternative

2. Supplementation: DAO enzyme supplements may be considered as subsidiary treatment for individuals with intestinal DAO deficiency 4

3. Medication: If antihistamines are indicated, treatment should be conscious and time-limited, with preference for 2nd or 3rd generation H1 antihistamines 4

Important Caveats

• Individual tolerance may vary, but fermented foods consistently show high histamine content
• Early dietitian involvement is recommended to prevent unnecessarily restrictive eating patterns 6
• The British Society of Gastroenterology recommends avoiding overly restrictive diets in patients with functional gastrointestinal disorders 6
• If symptoms persist despite dietary modifications, consider other diagnoses such as mast cell activation syndrome 6

Monitoring and Reintroduction

After a period of strict histamine avoidance and symptom improvement, some individuals may be able to gradually reintroduce certain foods in small amounts while monitoring symptoms. However, fermented foods including naturally cultured bread typically remain problematic for those with true histamine intolerance.