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clear search termsAsthma, Allergies and Joint Pain
(This is a sample entry from the SAFM Q&A Treasure Chest, a tool with hundreds of entries to support students with their client needs. Students get unlimited access as part of SAFM’s functional medicine training program.)
Student Question:
I have a 51 y/o client who has been seeing a naturopathic doctor for Asthma, Allergies, and Joint pain she has had for 17+ years. She’s been using a steroid inhaler for her regular asthma for many years. However, she says that none of what she’s added in this year with the naturopath has helped either the asthma or joint pain – at all. I know I need to do a deeper dive into upstream root causes (e.g. toxicity, mold), but what might be most helpful here for rapid relief? What am I missing? What about a food sensitivity test? Thanks!
This client has been doing…
- No grains.
- No dairy foods.
- No processed food.
- Increase animal fats (but only grass fed, etc.) to ~70% of diet.
- Throwing out cheap grapeseed oil and soy margarine (to reduce pro-inflammatory Omega-6 fats).
- Increase intake of fermented foods e.g. sauerkraut (but he did not put her on a probiotic)
- Take omega-3 oils EPA and DHA ProOmega fish oil (Nordic Naturals) – 1 tsp/day
- Take all the Fat soluble vitamins A, E, D, and K
- Take Biotics’ “Bio-D-Mulsion Forte” (liquid form of Vitamin D3 – 2,000 IUs) a day with breakfast.
- Blue Ice Fermented Cod Liver Oil (from Green Pasture) – 1 tsp/day (which yields ~10,000 IUs of naturally occurring vitamin A)
- Increase Vitamin K2 via plenty of grass-fed butter intake
Okay, now *before* you read on, take a moment to consider: how would You respond?
What interconnectedness do you see?
What would likely help this individual to get some rapid relief as you kick-off your work together?
SAFM Response:
Asthma is a chronic inflammatory disorder of the respiratory system. In the bronchioles of the lungs, we find inflammation (swollen walls, increased mucus, tightened muscles), and histamine is a major mediator. Since inflammation is generated by the immune system, asthma very often occurs hand-in-hand with other immune-mediated dis-ease in the body, especially when they have been sustained for a long time, such as environmental allergies, food sensitivity/allergy, eczema, acid reflux, arthritis, and chronic sinusitis. Many common triggers for asthma are allergies, including food sensitivities. To your point, there can be a different set of underlying root causes for the asthmatic state (dynamics such as toxicity, mold, or other environmental allergies are very common root causes) vs. common triggers for a bout of asthma (e.g. specific foods, stress). In the end, we must address Both for sustainable wellness.
Anyone looking at the list of recommendations your client is dutifully pursuing would agree that those are all theoretically healthy activities. Who could argue with any of those, right? Well, in this case, it pays to get up close….armed with an understanding of disease-specific interconnectedness. This is an oldy-but-goody journal article on the specific connections between histamine and asthma (here is a more recent research summary). Here are some specific recommendations which might be helpful:
- There is an attempt to eliminate dairy foods, yet there is encouraged high intake of butter? I understand the desire to take in more Vitamin K2, but I would not recommend butter intake for this client at all until there has been dramatic rapid relief and an opportunity to begin to work on the root causes. In my experience 100% of chronic asthma patients have immune reactivity to dairy foods. While the dairy protein content of butter is low, it is not zero, and I have actually seen this be in the way of relief in a few asthmatic clients in the past.
- For rapid relief, we need lower intake of histamine overall. Asthma is a histamine-mediated inflammatory dynamic, yet there is a recommended high intake of fermented foods (which contain high levels of histamine themselves!). I recommend fully avoiding all fermented foods for now until the histamine intolerance can be explored and reversed, including the fermented cod liver oil.
- I agree with eliminating refined seed oils. However, there is a recommended high intake of animal fats (which can promote high histamine release), especially arachidonic acid and especially in chicken eggs. For a person with appropriate balance between histamine intake/production and degradation, this is not typically a concern. We simply produce more DAO (diamine oxidase) in the gut to breakdown the histamine that is produced. But if DAO is limited (e.g. post-antibiotics or with dysbiosis or toxicity) or is not appropriately responsive to demand for more, this creates histamine overload. In this case, a more moderate fat intake that focuses on medium chain fatty acids (e.g. coconut oil) and oleic acid (e.g. extra virgin olive oil) will likely be a better interim balance. For now, I would also eliminate eggs.
- Ongoing use of steroid inhalers commonly creates yeast overgrowth, perhaps even thrush, in the upper respiratory and/or GI tract (due to localized immunosuppression). Over time (especially given the duration of this client’s suffering) this dynamic can create an allergy/sensitivity to yeast. This is also a way in which chronic use of conventional medication for asthma can continue to promote immune imbalance. Because these foods also contain high levels of histamine, I would eliminate all yeast/fungus-containing or -cultured foods e.g. beer, wine, vinegar, cured meats, kombucha, miso, tempeh). I would also consider doing a 10-15-day round of antifungal support in order to counter what has very likely built up in her GI tract (e.g. Renew Life’s “CandiSmart”); this will not address the issue long-term but will likely provide some relief to help establish a new normal with a lower histamine burden.
- Add 300mg boswellia and 1000mg quercetin twice daily. The regimen this client is using does not include a specific anti-inflammatory agent beyond the attempt to rebalance omega-3/omega-6 fats. The goal is to minimize the need for the inhaler, so the body can begin to recover from the ongoing use of steroids. Boswellia is particularly helpful for joint pain (a good alternative to NSAIDs in this case), but it also impairs leukotriene production and has been clinically shown to reduce asthma symtoms. Quercetin impairs mast cell degranulation directly.
- A daily Lactobacilus Rhamnosus probiotic (e.g. Culturelle). While many other probiotic species are histamine-producing, L. rhamnosus is histamine-degrading. (Of note, Saccharomyces Boulardii could also be helpful in rebalancing the Th1/Th2 immune reaction that is so often skewed in these individuals; however, given the likelihood of a yeast sensitivity in this particular person given her medications, I would not use a beneficial yeast probiotic).
- An activated B-complex once daily with food. While we acquire histamine from foods, we also generate histamine internally, the degradation of which requires methylation. I would check methylation status (e.g. homocysteine, methylmalonic acid). If data is not available, I would add a daily supplement that features a P5P form of Vitamin B6 (e.g. Thorne, Pure Encapsulations). And remember we always want to add/increase a B-complex low’n’slow to allow pathways to be supported progressively.
- Assess possibility of insufficient stomach acid (which can cause both magnesium and vitamin B12 insufficiency). You don’t mention it, but there is a very common association between chronic asthma and GERD. Allergy can promote insufficient stomach acid. This hypochlorhydria can then promote GERD, and frequent use of steroid inhalers can weaken the lower esophageal sphincter, also promoting GERD. Low stomach acid promotes more immune system exposure to allergenic proteins which can then worsen allergic hypersensitivity, creating a vicious cycle. In my own practice, every single person with chronic asthma also has had hypochlorhydria. Certainly this dynamic can bounce back as you address upstream root causes (e.g. hypothyroid, steroid use), but supporting it in the short-term is often key to improve nutrient absorption and to reduce downstream allergenic response in the gut.
- Assess magnesium status. By promoting muscle tightness and/or spasm, insufficient magnesium might be at play in exacerbating these symptoms. It is also important to ensure magnesium is repleted before beginning a Vitamin D supplement (magnesium is required to convert Vitamin D to its final active form in the body).
- I would also simplify her fat-soluble vitamin intake by using a single formula e.g. Allergy Research Group’s “Vitamin D3 Complete” which includes Vitamins A, E and K2 as well.
- Work on making the bedroom (the sleeping environment, in particular!) a non-allergenic environment. This may include an air filter, letting beloved pets sleep elsewhere (a common gotcha!), cleaning curtains/carpets, investigating sources of mold, etc..
There are many other options to consider, if necessary! For example, proteolytic enzymes taken on an empty stomach could help to break down immune complexes, especially to counter the joint pain. Or if boswellia is not enough, then curcumin might be added in combination. To counter histamine specifically, there are diamine oxidase (DAO) supplements that can be taken with meals to help the gut to break down more of what is consumed (shown to be quite helpful with asthma). However, in my experience, the above list is typically sufficient to bring dramatic rapid relief to this type of client profile. I will emphasize, however, what you said above that these interventions are only toward the goal of rapid relief, and the true root cause resolution remains important work! In my own practice, 100% of chronic asthma clients struggled with toxicity and benefit immensely from a few rounds of targeted detoxification support. But we must begin where the patient actually Is. In this particular case, healing the gut to slow/stop the chronic inflammatory dynamic requies eliminating the need for regular steroid medication; rapid relief is a key necessity for allowing that progression.
Yes it would be great to have food sensitivity test results. However, in this case, I would not recommend it. Any steroid medication is going to significantly impair the accuracy of an antibody-based food sensitivity test (such as IgG). By definition, steroid medications work in the body by inhibiting the immune system – and thus reducing inflammation as well as the adaptive immune system’s function of making antibodies to identify potentially threatening agents (like food!). This can be helpful for short-term triage and relief for an overwrought immune system, but long-term use is dangerous. So yes, it is important to be off of any steroidal medications at all for 8+ weeks prior to any antibody-based testing. Otherwise, all levels will likely be suppressed. As always, we want to remember that the gold standard of food sensitivity testing is elimination and structured reintroduction.
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This is such a great case to read, as I have a very similar one. Mine is a 64 yo man who had previously only mild asthma (flared up only once a year or so, and not severe symptoms. After getting COVID once (perhaps twice) and 2 subsequent pneumonia infections, his “lungs have never been the same”. his asthma is “severe” now – with coughing spasms all day and night for weeks on end. The spasms stop when he gags and tries to vomit, and then there is a severe acidic burning in his throat. Also diagnosed with pulmonary fibrosis. He was placed on steroid orally for 6 weeks, along with a steroid inhaler for 6 months (!).
He has been “mostly” gluten free for awhile, but still consumes cheese and milk in his daily coffee drinks, and has wine with dinner.
He is obese, takes Metformin, and an inhaler, wears a CPAP with 2L of 02 at night only.
Besides educating him about stress, dairy, yeast (wine), and 100% gluten-free, there are so many places to start….
Yes, so many places to start! And your cases is highlighting the importance of the true basics – those can be very powerful!
Also, you may be interested in this article regarding COVID and asthma exacerbation:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8674937/
I heard you talk about how it is possible to remove the yeast sensitivity via an elimination diet but the person may still exhibit symptoms of yeast intolerance. Can you explain that, please?
Yes, a person can develop an IgG and/or IgA sensitivity to the yeast due to intestinal hyperpermeability and an ongoing challenge from too many yeast-rich foods and also from an overgrowth of endemic yeast. Moreover, that sensitivity can persist beyond the dysbiosis has been corrected. This is because the immune system has a few redundant pathways that can recognize various parts of these organisms and can create a type of ‘memory’ towards these organisms. In addition there is also a good level of molecular mimicry between yeast and many common food antigens that can continue to trigger the ‘yeast sensitivity’. This study is quite dated but nonetheless fascinating and gives a good idea about the broad spectrum of how yeast may be affecting the system:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1379403/
If a person was using an antihistamine and a steroid for chronic sinus infections, are there any contraindications to using quercetin, bromelain, and DAO?
I am not aware of any particular contraindications for this combination, but you will want to use a formal contraindication tool to confirm this with her specific drugs. For example: https://reference.medscape.com/drug-interactionchecker or https://www.drugs.com/drug_interactions.html . Just be sure to introduce these one at a time with at least several days in between, so one can gauge if there is an unexpected negative reaction.
Can functional medicine help with IgE mitigated food allergies?
Yes. As this course highlights, the opportunity is to progressively address the underlying reasons why a unique person’s immune system is being hypervigilant e.g. repleting immune nutrient deficiencies, healing enhanced intestinal permeability (EIP), optimizing methylation, reducing inflammation, optimizing adrenal function, and (especially!) toxin avoidance (e.g. mold, heavy metals) and appropriate progressive detoxification. This can indeed reduce the severity/frequency of IgE reactions, especially if they are mild to moderate in intensity (e.g. naso-respiratory congestion, chronic urticaria). In my experience, severe or even life-threatening allergies (such as anaphylaxis to foods) do still require some type of immunotherapy to retrain the entrenched pattern of aggressive immune hypervigilance, and functional medicine interventions to address contributing imbalances and root causes (as above) can be quite synergistic.
Curious what type of targeted detoxification support would you recommend for confirmed mold toxicity? Activated charcoal? G.I. detox?
Detoxification is discussed in depth in the Toxicity, Detoxification & Heavy metals Deep Dive Clinical Course which I highly recommended as it is designed to acquire a deep understanding of the subject in order to safely and effectively help anyone to detox. Detoxification is not a black and white science and many factors must be considered when considering it to prevent causing harm to someone. The approach must take in consideration the person’s health, ability to detoxify and unique toxic load. There are multiple types of mycotoxins and they can often be found associated with other infections. Also, various agents bind with various toxins depending on their affinity to a binder. Using a multi agent formula such as GI Detox can help maximize the binding, unless there is clear identification of the actual mycotoxins via testing which can then be targeted more specifically.
Hi Tracy,
Here you explain how any steroid medication is going to impair the accuracy of an antibody-based food sensitivity test (such as IgG).
Does this also apply to any form of steroid medication? Would it also apply to steroid creams that you put on your skin?
I would imagine so since a know that the skin is a giant mouth, but wanted to check.
Thanks a lot!
Yes, topical steroid medication can affect an antibody-based food sensitivity test and if possible it is best to test when a person has been off of any steroid medications for at least a couple of weeks.
I’m wondering does Kimchi have yeast in it as well? Besides it being fermented and high in histamines, just wondering if it is yeast derived?
A simple google search will give you quick answers to these kinds of questions e.g. https://www.foodunfolded.com/how-it-works/kimchi-kombucha-how-its-made . Kimchi like sauerkraut is produced with lactic-acid producing bacteria, not yeast (though any fermented product that is not stored properly is vulnerable to after-the-fact yeast contamination).
Hi! I love this information! I was curious if protocols such as this are still effective for people who are actively increasing steroid medications (inhaler, nasal) in an effort to have a successful allergy shot result (ie: no anaphylaxis reaction to the allergy shot as well as it effectively reducing their severe environmental allergy symptoms and secondarily reducing asthma tendencies). It seems to me that it would be counteractive to try to bring down inflammation, detox, heal the gut, etc (especially if genetic predisposition for these problems exists) with functional medicine when they are also starting this type of conventional medical protocol with prolonged treatment periods (6- 12 months). Would it be better to wait until the conventional protocol is finished? Thanks!
We believe that functional medicine protocols often go hand in hand with conventional medicine solutions. The latter addresses the symptoms and the former goes after the root cause.
In this case, steroid treatment is necessary for allergy shot therapy to work. The objective of this combined therapy is to shift the immune system from high alert to low alert and eventually to its primary function of tolerance. The steroid levels need to be closely monitored and appropriately titrated to allow for this shift, and eventually, a person will need to wean off of the medication completely. The protocol outlined in the post offers supportive solutions that will facilitate the steroid wean off, eg. Boswellia would help balance this dynamic and make it easier to wean off of the steroid.
In regards to the Culturelle probiotic that is recommended, are there alternatives to that one that offer the same strain. I looked at that one and did not like the ingredients.
Certainly, there are a number of alternatives to Culturelle on the market. That popular brand was used as an example only for ease of access. Here’s a single-strain product from Klaire Labs:
https://klaire.com/v771-06-therbiotic-factor-1
and another, from Seeking Health, broader spectrum and specifically formulated with bacterial strains that lower histamine production:
https://www.seekinghealth.com/products/probiota-histaminx-60-capsules
As I said, many respectable supplement brands offer Lactobacillus rhamnosus containing probiotics and I encourage you to find a formula that you like.
So, given your comments about steroids and suppression of the immune system, would you expect someone on prednisone for Ulcerative Colitis to have low IgA on a GI Map Stool test?
As always, when applying the FM thinking principles to a client case you need to take the whole picture into account. On one hand, Ulcerative Colitis (UC) is characterized by higher levels of both IgA and IgG and that’s the very reason why corticosteroids are used often times very successfully for triage. It’s been shown a while ago (and has been confirmed multiple times since) that pharmaceutical corticosteroids have the ability to decrease the Ig levels. This is an old reference that holds true to this day: https://www.jacionline.org/article/0091-6749(78)90101-X/abstract This is another, newer study example that speaks to hypercatabolism of IgG upon Prednisone treatment: https://www.sciencedirect.com/science/article/pii/0091674972900942 That being said, whether or not you will indeed see low IgA on the Gi-Map will depend on the general state of the client’s immune system, how long they have been on Prednisone and their personal response to the corticosteroid (how fast they can metabolize immunoglobulins). It would make sense to ‘expect’ lower IgA levels, but that’s why ‘we test and don’t guess’. I could imagine a situation where the dose or duration wasn’t high and/or long enough to cause the IgA lowering OR another situation where IgA levels are low for a reason different than… Read more »
I recently watched the docuseries “The Dangers of EMF’s.” An interesting point was the study that showed mold growth increases when exposed to wi-Fi signal. I’m starting to ask my clients about their exposure to constant wi-fi and cell signals. There were many other biological impacts that I think we are going to have to consider this when working with clients.
Yes, we agree and appreciate the broad-base thinking about root causes of dis-ease. Thank you for your comment, Chris.
I love this case study and the detailed response. Would it be possible to get an update about this client? Maybe what worked and what did not? Were the asthma and joint pain reduced or alleviated entirely? Thank you!
Alas, this is an example of a one-time case study from one of the SAFM students posted in our treasure chest, where particulars depended on the client and the practitioner’s unique approach and we cannot provide updates on such cases.
These are all great recommendations that are specific to this individual. However my question is does the school teach how to be able to look at this case and then be able to come to these conclusions to make these specific recommendations on her own in order to best help the client?
Yes, it does! The School of Applied Functional Medicine offers a true deep dive into the physiology and biochemistry of the human body and teaches a specific, systems-based way of thinking not just bare facts. The focus of all the courses offered at SAFM is indeed on the applicability of all the basic knowledge that the functional medicine approach offers. There are many rich real-life case studies to learn from, live coaching calls, active practitioners community that allows plenty of interactions, exchange, and practice of the FM Concepts and also small-group support for each SAFM student. It does take time to master this way of thinking and this case is indeed quite complex and advanced and we are proud to say that our graduates are very successful in supporting such complex clients. You’re welcome to reach out directly to them and see for yourself:
https://practitioners.schoolafm.com/
What is the best way to support a client who is breastfeeding and has a high histamine issue? Has DAO been shown to be safe?
I could not find any studies on the DAO supplementation during breastfeeding and it’s safety. What’s interesting is that DAO is naturally present in the initial breastmilk production and its concentration decreases with time:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3446060/
To support a breastfeeding woman who strauggles with excess of histamine it makes a lot of sense to increase the intake of compounds that the DAO enzyme is dependent on. Those are vitamin B6, B12, iron, copper and vitamin C specifically. Thus, continuing a prenatal multivitamin post-delivery and while breastfeeding may be helpful in boosting these nutrients.
Avoiding any fermented foods while the histamine levels are high and reduction of the high-histamine or histamine-blocking foods seems to be an obvious choice as well.
Proper probiotic mentioned in the article would be helpful as well along with digestion support (such as ensuring strong stomach acid production).
I have a question with respect to the interconnectedness of histamine and inability to lose weight.
A 20-year-old client is having a skin allergy, that keeps coming up every day and she takes “Teczine” to control the itchiness.
The person has gained more than 10 pounds in the last 3 month (current weight: 148 lb, height: 5 ft). Her periods are normal but day one is highly painful with lot of cramps and bloating.
She used to eat an omnivorous diet and now she switched to a more vegetarian type of eating.
Blood work reports T4 1.4 and T3 2.3; CRP is 2.2; Glucose tolerance test showed 83 and 95 pre and the post-glucose dose of 2-hour gap.
Stress about studies is high, sleep is around 5-6 hours, exercise is in form of body weight and yoga, 5x a week
What can be at play with her not losing weight and having a daily skin allergy?
The recurring rash indicates that your client is struggling with histamine management. The big question is why such a young person has issues with histamine breakdown. It may be worth investigating whether it is because of poor microbial balance, a pathogen, poor dietary choices or issues with DAO enzyme production. You may appreciate this, slightly different case study that dives deep into how to address histamine issues: https://schoolafm.com/ws_qa/case-study-hives-thyroid-and-food/ Another thing that is at likely play is estrogen dominance – see the symptoms around her period – and her stress, which likely results in high cortisol levels. The combination of high estrogen and high cortisol is preventing her thyroid from working optimally by blocking the thyroid hormone receptors. Therefore, supporting healthy estrogen levels with liver support and ground flax seeds as well as better sleep and destressing techniques may be very helpful here. You can read more about estrogen and thyroid connection here: https://schoolafm.com/ws_clinical_know/low-thyroid-function-estrogen-dominance/ In addition, from the numbers that you are presenting it looks like her body struggles with the T4 to T3 conversion, and for this reason I’d make sure that your client has a good source of zinc, iron, and selenium and maybe even for a period of… Read more »
Is this valid for asthma in children too (supplement choices and doses)?
Thank you.
When working with children and helping them get relief from asthma an appropriate medical oversight is needed. This post describes a rich and complex case of someone who has more issues than asthma alone. Helping children with asthma, the safest place to start would be dairy and gluten elimination and gut healing and then start exploring some of the supplements. Here are a couple of posts that you may enjoy exploring as an additional read:
https://schoolafm.com/ws_clinical_know/intestinal-permeability-the-autoimmune-connection/
https://schoolafm.com/ws_clinical_know/seasonal-allergy-and-asthma-solutions/
I also highly recommend the “Understanding Allergies and Asthma” deep dive clinical course.
Yes, a very complex case! The SAFM response was wonderful
And very targeted for rapid relief of histamine mediated reactions.
I think it’s wise also to remove Omgea six foods and fermented Cod liver oil.
Hopefully with this added triage she will find relief. It’s very complex yet I believe all
Mentioned suggestions above will help. However, Querctin can be tricky. Some people with histamine intolerance have a difficult time on it for some reason. Otherwise it helps greatly. I would also check out If she’s drinking teas with tannins as it depletes DAO.. by the way, I’m on my phone and can’t see my response. Please excuse any typos ?
What a great detail information from Tracy. I learn so much from this post.
Thank you.