The
SIBO/Histamine
Bi-Phasic Diet
©
Dr. Nirala Jacobi,
BHSc, ND (USA)
www.thesibodoctor.com
Heidi Turner,
MS, RDN
www.foodlogic.org
4-6 week dietary protocol for managing histamine
intolerance and SIBO
Health care disclaimer: This treatment protocol is not intended as
medical advise and is best used with the guidance of a health care
professional. Please ask your doctor if this protocol is appropriate
for your condition before starting.
WHAT IS SIBO?
Small intestine bacterial
overgrowth is a condition
where bacteria which are
normally found lower in the
large intestine have overgrown
in the small intestine instead.
Abnormal amounts of these bacteria
cause a number of problems
1.
They damage the microvilli
– the absorptive
surface of the small intestine. This can lead to
malabsorption of nutrients. Microvilli are also
responsible for the digestion of small starch molecules
from food. When the microvilli are not working, the
bacteria use these small starch molecules to cause
fermentation. This bacterial fermentation produces
methane and hydrogen gas. Not only is this
uncomfortable, but causes further damage to the
microvilli.
Research has now shown that SIBO is a major cause of
intestinal permeability, or ‘leaky gut”, a condition
where partially digested food particles are absorbed
through the lining of the small intestines where they
can cause an immune reaction. Leaky gut also causes
bacterial by-products to be absorbed – a major trigger
for infammation.
2.
Leaky gut can also cause
malabsorption of nutrients
from your food which can cause a wide variety of
symptoms such as restless legs at night, fatigue,
skin rashes, muscle aching as well as a host of
digestive symptoms.
3.
The bacteria cause the
motility
of the small intestine
to slow down or work improperly, causing further
fermentation. Restoring proper motility in the small
intestines is a major focus of eliminating SIBO for good
and your practitioner is likely to prescribe a “prokinetic”
supplement or medication.
4.
Many people who test positive for SIBO will also have
a co-infection with fungal organisms, a condition known
as
SIFO
(small intestine fungal overgrowth) – the SIBO
Bi-Phasic diet helps to address this as well.
Visit
www.TheSIBODoctor.com
for more information
HISTAMINE INTOLERANCE
Histamine is a substance that is made inside the body as well
as found in certain foods. In many cases of SIBO, other foods
besides fermentable carbohydrates can be problematic. The
most common reactions are to foods containing histamine.
Histamine is a substance found in certain foods which can
cause symptoms in those with severely disrupted mucosal
lining of the small intestines. The depletion of the histamine-
digesting enzyme, diamine oxidase (DAO), yeast overgrowth,
or the prevalence of histamine producing bacteria are
often to blame. As the overgrowth reduces and this lining
repairs, histamines typically become less problematic. This
food sensitivity is known as Histamine Intolerance, or HIT.
Histamine is also made in the body and stored in cells known
as Mast cells. Reducing histamine foods can lower the “total
load” of histamine.
SYMPTOMS OF
HISTAMINE INTOLERANCE
Not everyone with SIBO has histamine intolerance. Beyond
the typical gastrointestinal symptoms, those with HIT often
experience symptoms that resemble allergies including
runny nose, itchy eyes, sneezing, hives, asthma, and chronic
cough, as well as other symptoms including headaches,
joint pain, anxiety and insomnia. Not everyone with these
symptoms has HIT but if you do, eliminating histamines
from the diet may provide you some additional relief during
treatment.
HISTAMINES IN THE DIET
Histamines in food typically increase with age and
fermentation. Fermented foods (vinegars, 24-hour yogurt,
wine/beer/cider, sauerkraut, kombucha, kimchi), aged meats
(bacon, sausage, ham, canned meats/fsh, smoked salmon,
bone broths) as well as tomatoes, spinach, eggplant, spicy
foods and chocolate are typically the most problematic for
those with HIT. Histamines also increase as food ages in the
refrigerator, so leftovers can be an issue for some. There are
other foods considered “histamine liberators” (HL) found in
certain vegetables, fruits, nuts and eggs.
Histamine liberators do not necessarily contain histamine but
can trigger a histamine response. Tolerance to these foods is
dependent on the individual.
A note about seafood: While seafood can easily build
histamine as it ages, very fresh/frozen seafood may be well
tolerated. White fsh such as halibut, sole and cod, and very
fresh salmon are typically the best tolerated.
HISTAMINE TOLERANCE
Each person is difference in their tolerance and threshold to
histamine foods. Some fnd that histamine liberating foods
are not at all bothersome to them but high histamine foods
are. Others must avoid them all to keep their symptoms
controlled. Most, however, will have some tolerance to
histamine foods and simply need to stay under their own
personal threshold, or the point at which symptoms begin.
HISTAMINE REDUCING FOODS
Try to keep this limited diet as anti-infammatory as possible
by including as many allowed plant-based foods as you
can and continue to test HL foods in as you are able. Use
anti-infammatory and mast cell-stabilizing herbs and spices
such as black seed oil/spice, turmeric, cilantro, parsley
and watercress, and DAO-stimulating olive oil to favor
foods. Try to eat as organically as you can afford to reduce
pesticides which can add to the histamine load for some.
Some with severe histamine intolerance fnd a diet high in
animal protein can trigger their histamine response. We do
not recommend avoiding animal protein as this can limit the
diet even further. Just make sure you are focusing on plant-
based fats, herbs, spices, vegetables, and fruits. If you are
early in treatment and plants are not well tolerated, cooking,
blending or juicing them may be better tolerated.
WHAT IS THE SIBO/HISTAMINE BI-PHASIC DIET?
This protocol has been developed for those suffering from SIBO and histamine
intolerance. It is not intended for long term use, but rather as a starting point for those
who have SIBO and food reactions. This diet protocol eliminates histamines and
fermentable carbohydrates. Once symptoms are controlled, moving into the SIBO
Bi-Phasic Diet is recommended.
Please consult with your practitioner before initiating
this protocol.
FERMENTED FOODS
Fermented foods such as cultured vegetables, sauerkraut,
kimchi, as well as miso and yogurt are wonderful for the
digestive tract as they contain high amounts of probiotics
or benefcial bacteria. But since these foods are high
in histamine, they may not be tolerated and it is best to
eliminate them from the diet for now. They can be introduced
back in as your symptoms improve and your practitioner
allows. Introduce no more than one tablespoon in any given
meal and increase only as tolerated.
GENERALLY AVOIDING ALCOHOL
Alcohol is a known gut irritant and disrupter of the normal
microbiome of the intestinal tract. It also reduces the amount
of DAO you produce and, if fermented (ie. beer, cider and
wine), contains high amounts of histamine. It is strongly
recommended to avoid all alcohol while on the Bi-Phasic
Diet. This is sometimes diffcult in social situations. In these
instances, clear spirits like vodka and gin are preferred over
beer and wine as they do not contain histamine, sulftes or
yeast. Please limit alcohol consumption even in these cases.
HISTAMINE ELIMINATION
AND REDUCTION
Combining a low fermentable diet with a diet that is low in
histamine can be challenging as the list of foods is narrow.
While all foods high in histamine and histamine liberators
have been eliminated from the diet in Phase 1, once your
symptoms have calmed, you are encouraged to test in
histamine liberating foods in an effort to expand the variety
and balance of the diet. Histamine containing foods are
noted with an “H” and should be avoided until later in the
treatment process. Histamine liberating foods are noted with
a “HL” and should be introduced and maintained in the diet
to your personal threshold. A food with an “F/HL” indicates
it is both a fermentable carbohydrate and a histamine
liberating food and should be avoided until you are ready
to add more fermentable carbohydrates back into the diet,
unless otherwise noted.
HISTAMINE ELIMINATION
AND RE-INTRODUCTION
IN THREE STEPS
STEP 1
Phase 1 of the Bi-Phasic Diet lasts two-four weeks. You
should avoid all fermentable carbohydrates, histamines and
histamine-liberating foods for at least two weeks before
considering expanding the histamine liberators (HL) into the
diet. Follow the food guide as to which foods to choose.
STEP 2
After two weeks on phase 1, and only once symptoms have
reduced, you can start testing HL foods if you wish. Use the
Phase 2 “Allowed” list as a guide for foods to introduce. Add
in one serving of a new HL food for three consecutive days.
If you tolerate, you can keep that food in the diet and layer
in another HL food in the same manner. Repeat, as tolerated.
If you start experiencing symptoms, reduce to previously
tolerated histamine load. Know that you may tolerate one
HL food over another, so if you do react to one, wait for the
symptom to calm and then continue testing with another. If
you do not tolerate a particular food, avoid it until you are
further into your treatment and test it again later, as you may
gain tolerance as the gut heals. If introducing any of the HL
foods creates a return of symptoms, you should return to the
baseline diet and wait until Phase 2 before testing again.
STEP 3
Your practitioner will advise you on when you are ready to
fully move on to the Phase 2 diet. This will involve adding in
higher histamine and histamine liberating foods, as you are
ready. When determining which foods to add in frst, always
consider which foods you miss the most and what will make
the diet more enjoyable. In this phase, you will also be able
to expand more fermentable carbohydrates into the diet, as
noted.
ALLOWED |
AVOID |
|
PROTEIN must be fresh |
Beef (organic, not aged), Lamb, Turkey (organic if available), Skinless chicken (organic), Wild/game meats |
HISTAMINE (H) HISTAMINE LIBERATORS (HL) Eggs (HL) Pork (HL) Seafood (H / HL) see “Histamines in Food” for info. Seasons/aged meats (ham, bacon, sausage, canned or smoked fsh and meats) (H) FERMENTABLE CARBOHYDRATES Legumes, Meats seasoned with garlic/onion |
DAIRY PRODUCTS |
Avoid all dairy |
Avoid all diary |
VEGETABLES unlimited |
Alfalfa sprouts, Bamboo shoots, Bok choy, Capsicum/bell peppers (not spicy), Carrot, Chard/Silverbeet, Chives, Cucumber, Ginger, Kale, Lettuce, Parsnip , Radicchio, Radish, Rocket/arugula, Spring onion (green part only), Sunfower sprouts, Witlof |
HISTAMINE (H) HISTAMINE LIBERATORS (HL) Capsicum (spicy/chili) (H) Eggplant (H) Olives (H) Spinach (H) Tomato (red) (H) green or yellow cherry tomato may be OK FERMENTABLE CARBOHYDRATES/STARCH (F) Caulifower, Corn, Garlic, Mushroom, Onion, Sweet Potato, Starch powder: arrowroot, corn, rice, tapioca |
VEGETABLES one serve per meal |
Asparagus – 2-3 spears Artichoke hearts – 1 / 8 cup Beetroot – 2 slices Broccoli – 1 cup Brussels sprouts – ½ cup Cabbage – ¾ cup Cabbage, savoy – ½ cup ( wombok) Celery – ½ stick Celery root – ½ cup Fennel bulb – ½ cup Green beans – 12 ea Leek – ½ ea Peas (green) – ¼ cup Potato (white) – 1 med size Pumpkin – 1 cup Snow peas – 5 pods Tomato (green or yellow cherry only) -5 ea Zucchini – 1 cup |
|
FRUITS two serves per day |
Blueberries – ½ cup Cantaloupe/Rockmelon – ½ cup Grapes – 10 ea Lime (to favour, fresh squeezed) Lychee – 4 Honeydew melon – ½ cup Kiwi – 1 ea Lychee – 5 Papaya – ½ cup Passion fruit – 1 ea |
HISTAMINE (H) HISTAMINE LIBERATORS (HL) Avocado (F/HL) – ¼ fruit can test in with HL but limited to recommended amount Banana (H) Kiwi (HL) – 1 ea Lemon (HL) (fresh squeezed, likely tolerated) Orange (HL) Raspberries (HL) Strawberries (HL) Tangerine (HL) |
PHASE 1 A
VOID FERME
N
TABLE C
A
RBOH
YDRATES, HISTAMINE AND HISTAMINE LIBERATING FO
All listed
quantities
are per
meal
ALLOWED |
AVOID |
|
FRUITS (CONT’D) two serves per day |
Paw paw – ½ cup Pomegranate – ½ small or ¼ cup of seeds Rhubarb – 1 stalk |
FERMENTABLE CARBOHYDRATES (F) Apple, Apricot, Blackberries, Canned fruit in fruit juice, Custard apple, Fig, Jam, Mango, Nashi, Nectarine, Peach, Pear, Persimmon, Plum, Watermelon |
GRAINS, STARCHES, BREADS AND CEREALS |
Avoid all, but if practitioner allows, can limit to: Quinoa – ½ cup White rice (basmati, jasmine only) – ½ cup cooked |
Avoid all, but if practitioner allows, can limit to: Quinoa – ½ cup White rice (basmati, jasmine only) – ½ cup cooked |
LEGUMES lentils, beans |
Avoid |
Avoid |
SOUPS |
Freeze large batches in single servings to reduce histamine production Homemade broths (organic only): chicken, beef, lamb, turkey, 2-hour broths only |
Bone broth (H/F) Canned soups and soup bouillon (H/F) |
BEVERAGES |
Tea (herbal) Water (fltered only) |
(All H): Alcohol, Beer, Cider, Club Soda, Coffee, Energy drinks, Fruit juices (H/F), Kombucha, Liqueurs and spirits (dark), Seltzer water, Soft drinks, Tea (black, green), Wine |
SWEETENERS |
Yeast overgrowth: limit /avoid all except Stevia Dextrose/glucose, Organic honey (clear) – max. 2 tbsp per day, Stevia (100% pure, no inulin) |
Artifcial sweeteners (avoid completely) (HL), Cane sugar, Chocolate cocoa, Cacao (H/F), Maple syrup, Sugar alcohols (xylitol, mannitol, sorbitol) |
NUTS/SEEDS |
Coconut four/shredded – ¼ cup Coconut milk (no thickeners) – ¼ cup Coconut cream – 2 tbsp Macadamias – 20 ea |
All other nuts/seeds (HL) – can introduce upon practitioner’s approval to low FODMAP guideline recommendations |
CONDIMENTS |
All fresh and dried herbs and spices except those noted in ‘Avoid’ Green salsa (without onions/garlic) – 1-2 tbsp |
HISTAMINE (H) HISTAMINE LIBERATORS (HL) Capsicum/peppers (spicy): chili, cayenne and their sauces (H) Allspice, Cardamom, Cinnamon, Cloves, Nutmeg (HL) Fermented sauces (such as fsh, soy, coconut aminos, oyster, tamari) (H) Fermented foods (such as kimchi, sauerkraut, pickles) (H) Mayonnaise (H), Mustard (H), Vinegar (H), Tomato sauce/ketchup (H), Salsa (H) FERMENTABLE CARBOHYDRATES/STARCH (F) READ LABELS! No Asafetida, Chicory root, Garlic, Gums/carageenan/thickners, Maltodextrin, Starches, Sugar, Onions, |
FATS/OILS |
Butter, Coconut, Flax (low lignin) Ghee, Grapeseed, Infused (garlic,lemon, onion), Olive, MCT, Sunfower |
Palm, Soyabean, Pumpkin, Sesame (HL), Walnut |
ea = each tsp = teaspoon tbsp = tablespoon
PHASE 1 A
VOID FERME
N
TABLE C
A
RBOH
|
ALLOWED |
|
PROTEIN must be fresh |
Beef (organic, not aged), Chicken (organic), Eggs (HL), Lamb, Pork (HL), Seafood (H/HL) see “Histamines in Food” for info, Turkey (organic if available), Wild/game meats |
HISTAMINE (H) HISTAMINE LIBERATORS (HL) Seasons/aged meats (ham, bacon, sausage, canned or smoked fsh and meats) (H) FERMENTABLE CARBOHYDRATES Legumes, Meats seasoned with garlic/onion |
DAIRY PRODUCTS |
Butter, Ghee Homemade yoghurt (plain, organic) (H) this is often well tolerated – reintroduce upon your practitioner’s advice |
Avoid all other diary not on allowed list |
VEGETABLES unlimited |
Alfalfa sprouts, Bamboo shoots, Bok choy, Capsicum/bell peppers (not spicy), Carrot, Chard/Silverbeet, Chives, Cucumber, Ginger, Kale, Lettuce, Parsnip , Radicchio, Radish, Rocket/arugula, Spring onion (green part only), Sunfower sprouts, Witlof |
HISTAMINE (H) HISTAMINE LIBERATORS (HL) Capsicum (spicy/chili) (H) Eggplant (H) Olives (H) Spinach (H) Tomato (H) green/yellow cherry tomato may be OK FERMENTABLE CARBOHYDRATES/STARCH (F) Canned vegetables, Corn, Garlic, Mushroom, Onion, Sweet Potato, Starch powder: arrowroot, corn, rice, tapioca |
VEGETABLES one-two servings per meal |
Asparagus – 2-3 spears Artichoke hearts – ¼ cup Beetroot – 2 slices Broccoli – ½ cup Brussels sprouts – ½ cup Cabbage – ½ cup Cabbage, savoy – ¾ cup ( wombok) Caulifower – ½ cup Celery – 1 stick Celery root – ½ cup Fennel bulb – ½ cup Green beans – 10 ea Leek – ½ ea Peas (green) – ¼ cup Potato (white) – 1 med size Pumpkin – 1 cup Snow peas – 5 pods Tomato (green or yellow cherry) – 5 ea Zucchini – ¾ cup |
|
FRUITS two servings per day |
Avocado (F/HL) – ¼ cup Blueberries – ½ cup Cantaloupe/Rockmelon – ¼ cup Cherries – 3 ea Grapes – 10 ea Honeydew melon – ¼ cup Kiwi (HL) – 1 ea Lemon (HL) – use to favour, fresh squeezed Lime (HL) – used to favour, fresh squeezed |
HISTAMINE (H) HISTAMINE LIBERATORS (HL) Banana (H) Orange (H) Tangerine (H) FERMENTABLE CARBOHYDRATES (F) Apple, Apricot, Blackberries, Canned fruit in fruit juice, Custard apple, Fig, Jam, Mango |
PHASE 2 TEST HISTAMINE LIBERATING (HL) FOODS
ALLOWED |
AVOID until further notice |
FRUITS two servings per day (CONT’D) |