CLEM & THYME INTERN PROJECT

Introduction and Course Overview

The dietary management for mast cell activation syndrome:

Although many people have similar symptoms, there is no one way to approach it.
Treatment and dietary strategies differ amongst individuals.

It is easy to take foods away, and the client may feel better if foods are taken away, but food
intolerance is a symptom of a dysregulated immune system. In most cases, it is not the cause.

As dietitian’s job is not only about dietary management, but also about keeping an eye on the
driver of the symptoms. Once you keep an eye on the drivers, you are in a better position to
expand the diversity of the client’s diet.

Mast Cell Basics

What are mast cells?

Mast cells are the “foot soldiers” of immune system. They are built in bone marrow and
found in all connective tissues through the body (gut, skin, blood, nerves, lungs, lymph).
They manage IgE mediated allergies, immune responses, and hormonal and
neurotransmitters stimulation. They are protective and supportive!

What happens when mast cells are activated?

They degranulated!

Degranulation releases hundreds of immunomodulators:

 Histamines and other biogenic amines

 Cytokines
 Chemokines
 AA products
 Chemoattractant
 Growth factors
 Neuropeptides
 Proteoglycans
 Proteolytic enzymes
They signal white blood cells and other cytokines, encourage inflammation, and regulate
hormones (ex: thyroid hormones and estrogen).

What is Mast Cell Activation Syndrome (MCAS)?

MCAS is a form of mast cell disorder or mast cell activation disease:

 Clonal Mast Cell Proliferation Disorder (mastocytosis, cancer)

- Rarer form in which the body makes way too many mast cells.
 Mast Cell Mediator Disorders (idiopathic, MCAS)
- Common form
 Reactive Mast Cell Mediator and Cell Proliferation Disorder (MCAS)
- Too many mast cells that are leaky due to drugs, foods, infections, etc.

*Note: MCAS is form of Mast Cell Mediator Disorders and Reactive Mast Cell Mediator and
Cell Proliferation Disorder, but NOT a form of Clonal Mast Cell Proliferation Disorder*

What is MCAS specifically?

With MCAS, mast cells become leaky and unstable through less specificity and increased
hypersensitization.

- They are not simply triggered by pollen, estrogen production, or waking up in

the morning anymore… they are now reacting to benign stimulation like smell,
taste or even stress.

This chronic and/or consistent release of inflammatory mediators binding to tissues throughout
the body impacts multiple systems and causes increased associated symptoms.

What systems are impacted?

 Central Nervous System

 Cardiovascular system
 Gastrointestinal tract
 Dermatological
 Respiratory
 Reproductive
 Allergy/Inflammation
What are the associated symptoms?

Any, all, or a combination of one or more of these symptoms is common with MCAS.

 Neurological: anxiety, insomnia, numbness/tingling in extremities, tinnitus, headaches,

depression, severe fatigue, lightheadedness, weakness, vertigo, syncope, fibromyalgia
type pain, dysphagia
 Cardiovascular: low/high blood pressure, tachycardia, temperature fluctuations
 Gastrointestinal: Bloat, post prandial fullness, excess acid production/heartburn,
diarrhea/constipation, abdominal pain, nausea/vomiting
 Dermatological: flushing, urticaria, eczema, dermatographia, bruise/bleed
 Respiratory: asthma, shortness of breath, dyspnea
 Reproductive: dysmenorrhea, worsening at menses/peri/menopause, miscarriage
 Hormonal: hypothyroid
 Allergy: rhinitis, itchy eyes, urticaria, eczema, sneezing, sore throat, chronic cough
 Atypical reactions to food/supplementation/drugs

*Top three areas tend to be the neurological, cardiovascular, and gastrointestinal symptoms*

MAST CELL ACTIVATION SYNDROME BASICS: PATHOLOGY,

TESTING, STABILIZATION, AND TRIGGERS.

Overview and Histamine Basics

What is histamine?

Histamine is a biogenic amine that most commonly impacts physiological symptoms associated
with MCAS. When there is excessive mast cell activation, there is excess histamine production.

Although it is important to regulate, it is critical as it is used for several biological purposes:

 Digestion (gastric acid secretion)

 Circulation (blood pressure, temperature)
 Respiratory (lung function)
 Mast cell/allergic/inflammatory response
 Estrogen metabolism (estrogen production, menstrual cycle regulation)
 Sleep cycle (support waking)
 Neurotransmitters (hyper excitatory neurotransmitter)
How do we build histamine?

Histamine is built by converting histidine to histamine via histidine decarboxylase (HDC). We

store it in mast cells, basophils, and enterochromaffin-like cells. Both mammals and bacteria
produce HDC.

How do we break down histamine?

Histamine is metabolized by diamine oxidase (DAO) via oxidation and histamine N-methyl
transferase (HNMT) via methylation.

DAO:

 Produced by mucosal cells and primarily found in intestines, kidney, and placenta.
 Its deficiency is thought to be the most problematic in histamines intolerance
 When someone becomes pregnant, DOA helps to protect fetus from histamine reactions

HNMT:

 Found intracellularly in the cytosol of lung, kidney, liver, ovary, prostate, and spleen cells

What happens when we have too much histamine?

An increase in histamine production can lead to a deficiency in both DOA and HNMT, causing
excess circulating histamines.

Excess histamine can have an adverse impact on all the area histamine regulates. It does this via
activation of H1, H2, H3 H4 receptors which are placed throughout the body:

 Gastrointestinal Tract: H1, H2, H3, H4

 Respiratory: H1, H2, H3
 Skin: H1, H2, H4
 Nervous system: H2, H3, H4
 Circulatory: H1, H2

How To Diagnose MCAS: Testing and Diagnostics

Urinary Histamine Metabolites – Most reliable

 24-hour N-methyl Histamine

 PGD2 or its metabolite 11-b PGF2
 LTE4
Tryptase, serum – Less reliable, but always ordered

 Always ordered and always comes up negative in MCAS so makes it a challenge when
doctors only focus on the tryptase
 Patient should be in active flare and labs should be drawn between 30 minutes and 2
hours after an episode
 Ideally two reads (one when flared and one when not flared to see the differential)

Serum Histamine

 Histamine breaks down fast in blood stream so if flare is not super active, histamine may
have already been broken down and moved into urine

Intestinal biopsy for mast cell proliferation

 Typically done by GI doctor during an endoscopy or colonoscopy

TAKEAWAYS: Testing is tricky, and timing is important!

- Can see many false negatives

- Best to have two readings: one flared and one not (especially with tryptase)
- Some are highly temperature sensitive
- What is being tested for may not be what is being released from the mast cell
- Don’t always look for testing to be positive to diagnose MCAS specifically

Diagnostics

If you do not have access to labs or are questioning the accuracy of the labs, Dr. Afrin and Dr.
Molderings have produced a concise and practical guided questionnaire to diagnose mast cell
activation disease. A score above 14 indicates possibility of MCAS.

 If labs are negative but the patient’s symptoms align with MCAS and they are responding
well to stabilization methods (H1, H2 blockers, ketotifen, etc.) then you can treat the
illness like MCAS even without a diagnosis.
 If labs are negative and there is no response to treatment, then you may need to consider
other diagnosis
 The most common alternative diagnosis that presents like MCAS is Chronic
Inflammatory Response Syndrome (CIRS) which is a reaction to mold
Stabilization: OTC, Prescription and Supplementation Options (First Therapies)

OTC:

First, start with H1 blockers:

 Loratadine – Claritin
 Cetirizine – Zyrtec
 Fexofenadine – Allegra
 Levocetirizine – Xyzal
 Diphenhydramine – Benadryl

Cycle through each one to figure out A.) Does your body tolerate it? B.) Does it help to
stabilize and reduce symptoms?

If no, stop the medication and let body calm down before moving on to the next one.

If yes, stop the medication and let body calm down, but still move on to the next one to
determine A.) Does the body tolerate this one? B.) Does it stabilize and reduce symptoms
better?

Then, move on to H2 blockers:

 Famotidine – Pepcid, Zantac

 Cimetidine – Tagamet

Cycle through each one to figure out A.) Does your body tolerate it? B.) Does it help to
stabilize and reduce symptoms?

If no, stop the medication and let body calm down before moving on to the next one.

 If yes, stop the medication and let body calm down, but still move on to the next one to
determine A.) Does the body tolerate this one? B.) Does it stabilize and reduce
symptoms better?

All about finding the right recipe! May need to be compounded if reactive.

Medications:

 Leukotriene Inhibitor – Montelukast (Singulair)

 Mast Cell Stabilizers – Cromolyn Sodium (1 ampule QID 30 mins before meals)
Ketotifen (compounded, 1 mg BID)
 Low Dose Naltrexone – 4.5 mg QD
 Benzodiazepines – Ativan, Valium, Klonopin, Xanax
 Hydroxyzine
  Omalizumab – Xolair
 Aspirin (do not test without medical supervision! Severe allergy seen leading to
anaphylactic shock)
 Steroids (last resort!)

Montelukast, Cromolyn Sodium, and Ketotifen most used and most commonly successful.

Supplements: (ALWAYS TAKE TOLERANCE INTO ACCOUNT)

Anti-allergy and mast cell stabilization:

 Quercitin: great to use in relation to food intolerance, taking 30 min before meals has a
great mast cell stabilization affect, lots used and in very high dosages
 Specialized Pro-resolving Mediators: fractions of essential fatty acids incorporated into
the cell to prevent cell from activating and building inflammatory mediators, well
tolerated and highly effective
 Palmitoyl Ethanolomide: mast cell stabilizers, terrific for pain management
 Perilla seed extract: mast cell stabilizer
 Melatonin: helps with sleep and regulation of histamine cycle
 Bioflavonoids – Luteolin, Rutin
 Resveratrol: mast cell stabilizer
 Butyrate: mast cell stabilizer particularly when gut is active (most times)
 Stinging nettles: antihistamine
 Berberine: mast cell stabilizer
 Curcumin: mast cell stabilizer

Formularies: (good for clients who are tolerant to other methods)

 Mast Ease by Beyond Balance

 HistaQuel from Research Nutritionals
 Aller-All from Protocol for Life Balance
 Neuroprotek from Algonot
 Histaid from Quicksilver
 Histaeze from Designs for Health

Electrical System Support:

Severe dehydration has been shown to increase histamine release, so daily electrolytes have been
very helpful in balancing the system. If client is not tolerance with electrolytes, choose ones
without additives or add Himalayan Sea salt to water.

 80-100 ounces of filtered water per day (especially during flare ups)
Immune System Support:

 Vitamin D – test and then dose

 Fatty acids – omega 3 (flax, fish, algae), specialized pro-resolving mediators, GLA
(evening primrose oil or black currant seed oil)
 Quality multivitamin without herbals

Where to start?

 It depends on who is on team (MD, ND, non-prescribing provider) and what the client
wants!
 Common to begin with H1/H2 trial.
 If still reactive or unable to tolerate, progress to prescriptions or mast cell stabilizations.

Dr. Turner Recommendation:

Start with electrolytes and/or sea salt in water to ensure hydration. Then, move to fatty acids (fish
oil, EPO, SPMs) and incorporate a simple, good quality multivitamin to cover bases.

Move in with preferred mast cell stabilizers (Quercitin, SPM, PEA). If client is still not tolerating
and is open to it, begin H1/H2 trials.

Tolerance Issues?

 Oral tolerance to anything can be tricky, even to stabilizers!

 Medications vs supplements? (In a lot of cases, medications are better tolerated than
supplements)
 Start with single ingredients and expand to formularies as tolerated
 Single supplement introduction over 5-7 days
 If there is no tolerance, may need to take breaks and stabilize in other ways.

Always look for A.) tolerance and B.) efficacy

Identifying MCAS Triggers: Using the SHEDD Assessment

Once stabilized, the next goal is to determine the client’s triggers and establish goals. The most
common goals are to determine food intolerances, optimize nutritional status, and expand the
diversity of the diet.

What is the main obstacle to successfully reaching these goals? A hypersensitive immune
system. We must figure out how to calm the system because once you calm the system, you
build a diet!
 How do we calm the system? SHEDD

1.) Relieve Stress

- Stress hormones triggers mast cell activation and subsequent inflammation
- Stress impacts digestion and microbiome health
- The longer stress goes on, the more active the stress response becomes and can
encourage limbic system injury
- The more intense the long term the stress, the more likely it is a player in their mast
cell activation

How do we relieve stress?

Assess what kind of stress they are currently experiencing, recommend appropriate strategies to
manage current stresses, suggest simplifying life, encourage exercise and sleep, suggest
meditation to calm nervous system, etc. If they are stress intolerant, consider limbic system
training

2.) Monitor Hormones

- Estrogen dominance and/or progesterone deficiency (especially in females) triggers
onset of MCAS as there is a correlation between excess estrogen and mast cell
activation.
- Testosterone deficiency (especially in males) triggers onset of MCAS as there is an
inverse relationship between testosterone and histamines
- Adrenals related to stress (support with herbs!)
- Thyroid (mast cells in brain store TSH and T3, hypothyroid condition may increase
mast cell proliferation)

What is the most common hormonal issue associated with MCAS?

Estrogen dominance is the most common hormonal issue.

 Mast cells have estrogen receptors which means there is a tight relationship as they
regulate menstrual cycle.
 Excess estrogen can trigger excessive mast cell activation. Symptoms include PMS and
worsening symptoms of cycle/ovulation.
 Estrogen dominance can also be related to detoxification issues (more circulating
estrogen, most mast cell activation)
 Consider endometriosis (pelvic pain, infertility symptoms)

3.) Consider Environment

- Seasonal allergies
- Environmental toxicants (plastics, glyphosate, off gassing, heavy metals, chemicals in
body care, air fresheners, etc.)
 - Air quality
- Water quality
- Lyme disease (strong correlation with MCAS so assess client travel history and
symptoms)

What are the top environmental triggers? Mold and Electro Magnetic Fields

Mold/Mycotoxins

 One of the most common drivers observed in MCAS

 Mycotoxins from mold trigger severe immune reactivity and impairs multiple organ
systems
 Drives GI immune dysregulation including fungal/bacterial overgrowth, dysbiosis,
inflammation, and food intolerances
 Sinus inflammation and lymphatic congestion
 As a health care provider who hopes to specify in MCAS, take mold masterclass

Electro Magnetic Fields

 Studies suggest that EMFs may impact mast cell activation in brain, gut, and thyroid
 Nervous system hypersensitization
 5G shown to impact top layers of skin (asses how much time your client spends looking
on phone, computer, and television)
 Reduces SOD, reduced glutathione, and increases free radicals

4.) Monitor Digestion

- Mast cells and histamine receptors line the digestive tract, so, chronic activation can
drive intestinal inflammation, permeability, and food intolerance
- Food intolerance is a symptom of dysregulated immune system of the gut
- Dysbiosis is extremely common with MCAS! Can be primary or secondary, but most
observed for food intolerance (SIBO, SIFO, candida, parasites, other opportunistic
bacterial infections)
- Testing is critical! (Lactulose breath testing to rule out SIBO, stool testing to assess
for parasites, yeast, problem actors, inflammation, enzyme deficiency, organic acid
Test could help rule in/out suspected SIFO
5.) Focus On Diet (There is no MCAS diet!)
- Food intolerances are a SYMPTOM of a larger immune dysregulation
- Dietary elimination stabilizes through reduction of triggers!
- Food intolerances are typically reversible, and the goal of elimination work should be
to manage symptoms to provide stability while you look at root causes
- With MCAS, multiple food intolerances are common
- Since MCAS can be driven by multiple factors, each person’s intolerances will be
different too
- Any food can be problematic, most clients will already be off several foods
 Dietary Management: Food Intolerances

What is the primary goal of dietary management? EXPAND THE DIVERSITY OF THE
DIET!!!

Where do we start?

 Maintain consciousness. This is a highly sensitive population which can be sensitive to

foods, smells, contact, emotion, supplementation, food, etc.
 Take is slowly and simply. “Fairy dust introduction” through sprinkles, drops, and
tastes. Observe introductions over several days. Single ingredients are always best. Can
be a painstaking process for both you and the client to find the right “recipe” for
stabilization.
 Be patient and encourage patience. Listen and avoid dogmatic thinking! Build trust and
collaborate with your client.

Histamine Intolerance

Histamine intolerance is a condition in which the gut does not have enough DAO to breakdown
dietary histamine. High histamine in gut = high systemic histamine.

Histamines in Foods:

The histamines in foods increase with fermentation or aging. Bacteria convert histidine to
histamine (using HDC) in food.

 Fermented foods: sauerkraut, kimchi, miso, wine

 Aged foods: charcuterie, canned tuna/salmon/sardines, cheese, vinegars
 Decaying foods: leftovers, spoiled foods, fish
 Tomatoes, spinach, eggplant, avocado
 Wide variety of histamine load between samples make it difficult to measure

Clinical HIT:

 Study shows an average of 3 or more systems involved in 97% of patients with HIT, with
an average of 11 symptoms per patient
 Two more symptoms with improvements through histamine dietary exclusion are
indicative of HIT
 Very important to note that one does not need to have all the symptoms to have HIT

Other Histamine Contributors:

 Spermine, spermidine, cadaverine, putrescine, tyramine, tryptamine, phenylethylamine,

agmatine
  Many biogenic amines require DAO to metabolize, so even though a food doesn’t contain
histamine, it can still cause a reaction if there is a DAO deficiency in the intestinal lumen,
examples include citrus, chocolate, and red beans
 Multiple bacteria have been shown to produce histamine through action of HDC

Many microbes can degrade histamine and act to counterbalance the histamine being produced
by other organisms:

 B. Infantis
 L. Rhamnosus GG
 L plantarum D1033
 B longum

MCAS vs HIT:

 Those with MCAS have an increase in circulating histamine from excessive mast cell
stimulation, while HIT is a result of reduced DAO in gut.
 Not everyone with MCAS has HIT and vice versa, but eliminating histamines from diet is
a good first step

Histamine Elimination Diet:

 Low histamine diet for 3-4 weeks to get a sense of efficacy

 If symptoms dramatically change, then do a slow reintroduction of higher histamine
foods, adding in a higher histamine food every 2-5 days to determine their personal
tolerance
 If symptoms do not improve on the diet, still do a gradual introduction back in but at
faster pace

How To Expand the Diet:

 Offer supplementation to support histamine metabolism and mast cell stabilization

- B6 in activated form of P5P: 50 mg QD, watch for toxicity!
- Zinc/copper
- Magnesium (direct relationship between Mg and DAO)
- Omega 3 fatty acids
- Vitamin C (antihistamine)
- Stinging nettle (blocks histamine production, H1 antagonist, blocks tryptase release
from mast cell)
- Nigella Sativa (antihistamine)
- Probiotics to tolerance
- Quercitin (mast cell stabilizer)
- Palmitoyl Ethanolomide
 Build back more histamines as tolerate and as you continue to uncover underlying causes
to the intestinal inflammation
What foods should be encouraged?

 Foods high in DAO (pea shoots, pea sprouts, micro greens)

 Foods supportive of DAO production (olive oil)
 Foods high in vitamin C (blueberries, broccoli, cauliflower, mango, papaya
 Foods high in quercitin (apples, onions, kale, broccoli, blueberries)
 Foods high in omega 3 fats (fresh salmon, fresh halibut, hemp, chia, and pumpkin seeds)
 Foods high in zinc (fresh animal proteins, nuts/seeds)
 Foods high in B6 (beef liver, dark leafy greens but NO spinach)
 Foods high in B12 and iron (liver, animal protein)

Histamine and FODMAPS Intolerance

What are FODMAPS? Fermentable Oligo- Di- Mono-saccharides And Polyols

What are FODMAPS problematic:

 Short chain CHO/fibers are poorly absorbed in the small intestine, leading to an increase
in osmotic pressure increasing the water in the intestinal lumen. This leads to bloating
and discomfort
 Increased fermentation by intestinal bacteria may increase intestinal inflammation
 Symptoms include gas, bloat, diarrhea, acid reflux, abdominal pain, fatigue

What does FODMAP intolerance mean? Anything that could drive intestinal inflammation

 SIBO, SIFO, h. pylori, other dysbiosis

 IBD
 Inflammation from medications, toxins, and stress
 Lymphatic congestion
 Dysmotility/gastroparesis
 Liver detox issues
 Functional digestive issues
 Vagal nerve dysfunction
 Other food intolerances

FODMAP testing to consider:

 Lactulose breath test (SIBO)

 Stool testing (IBD, dysbiosis, inflammation)
 IBD serum (CRP, calprotectin)
 GI consult
FODMAP and Histamine Intolerance:

Both histamine and FODMAP intolerances are common. In general, high FODMAP foods are
low in histamine and vice versa, this makes the diet VERY lean. This diet can be referred to as
the low histamine bi-phasic diet: the initial phase for 2-4 weeks, second phase for 2-4 weeks and
continue building as inflammation reduces and tolerance allows. This is a short-term diet options
and it is very important to be treating underlying causes and doing gut stabilization to expand the
diet within a reasonable time frame.

Mast Cell Activation and Sulfur Intolerance

Sulfur is the third most abundant mineral in the body. It has many different functions, including
detoxification.

Dietary sources of sulfur include animal proteins, eggs, dairy, beans, nuts, dark leafy greens,
onions, garlic, leaks, shallots, well and mineralized water, and many supplements.

How does sulfur metabolize?

 MET and CYS metabolism via methylation and

transsulfuration
 Cysteine will be converted into sulfide which will then
be converted into sulfite and then sulfate which can be
used for detoxification.
 Sulfite requires sulfite oxidase (molybdenum dependent
enzyme) to become sulfate

Hydrogen Sulfide Gas:

 Gasotransmitter involved in nerve function, protects

cells from oxidative damage, regulates blood pressure, vasodilation, and reduces
inflammation response
 Organic sulfur, sulfide, sulfite, and sulfate can all be converts to hydrogen sulfide gas and
vice versa
 Other contributors include sulfate reducing bacteria
 It is beneficial in small amounts, but toxic in large amounts
 Too much interrupts electron transport chain and depletes CoQ10 which helps to break
down hydrogen sulfide gas
 Patients may benefit from supplemental CoQ10

What is sulfur intolerance?

Sulfur intolerance is an issue with sulfur metabolism that leads to an excessive amount of
hydrogen sulfide gas production.
What can go wrong?

 Most talked about: Molybdenum deficiency leading to sulfite oxidase deficiency =

increase in sulfites and decrease in sulfates

What happens if we have too many sulfites?

Excess sulfites increase reactive oxygen species which increases cellular damage and reduces
ATP production. The sulfites will convert to more hydrogen sulfide gas which can either be
converted back to sulfate or not.

Sulfur Intolerance Possibilities:

 Interruption of sulfite to sulfate

 Interruption in conversion of homocysteine to cysteine and/or cysteine to sulfate
 Increase in GI hydrogen sulfide gas producing bacteria

Increase in hydrogen sulfide gas production= Increase in neurodegenerative and inflammatory

symptoms

Common Sulfur Intolerance Symptoms:

 “Toxic feeling”
 GI: heartburn/belching, diarrhea/constipation, smelly gas, pain
 Neurological issues
 Joint pain
 Skin inflammation
 Interstitial cystitis or bladder pain

Sulfur Intolerance Assessment:

 Look at history – have they been diagnosed with H2S SIBO or ulcerative colitis?
 Align symptoms
 Onset with high-protein diet? Immediate or delayed?
 Feels better on vegetarian/vegan type diet? Aversion to meat?
 Worsening of addition of sulfur containing supplementation or during detox?
 Well water?
 Sulfite sensitivity/allergy?
 Reactivity to sulfur-based antibiotics or medications?

How to Manage Sulfur Intolerance:

 Pull supplements first!

 Support pathways via molybdenum, B vitamins, and CoQ10
 Support detoxification
 - Epsom salt baths
- Sauna/sweat
- Skin brushing
- Lymphatic massage
- Enema (if constipation remains)
 Manage Diet: A 1–2-week reduction of high sulfur foods often yields quick results
- Vegan or limited meat diet minus brassicas/allium/greens
- Diet is higher in fats, low sulfur vegetables, fruits, and lower in protein
- Avoid foods high in methionine: animal protein, eggs, tofu, dairy, some nuts, beans,
quinoa
- Avoid foods high in cysteine: eggs, dairy, beans, oats, lentils, some nuts
- Avoid brassicas, darky leafy greens
- Avoid alliums
- Avoid well water

Sulfur Intolerance Testing Considerations:

 Hydrogen sulfide gas SIBO: 3-hour lactulose breath test (Trio Smart Breath Test or look
for flatline on standard)
 Organic Acids Test: fungal markers, mycotoxins
 Stool test (looking for desulfovibrio, bilophilia, E. coli, klebsiella, candida, salmonella)
 Homocysteine elevation

Overview:

 Observe symptoms
 Diagnostics (H2S SIBO, UC, candida, mycotoxins, Lyme disease)
 Trial elimination
 Support pathways (B vitamins, molybdenum, CoQ10)
 Reintroduce foods to tolerance
 Continue to treat and/or assess for underlying drivers
 Keep your eye on the diet. Goal is to get more sulfur BACK into diet
 If sulfur intolerance continues to exist, you need to keep digging for or treating
underlying causes

Oxalate Toxicity

What are oxalates? Oxalic acids in plants are bound to sodium and potassium, creating soluble
salts called oxalates. Oxalates can bind to magnesium, calcium, iron, or zinc in the gut making
them insoluble. Any undigested oxalates are typically excreted through stool with minimum
systemic absorption.

 Oxalates are taken through the diet, and we can convert them from environmental
additives and produce them endogenously
  Founds in antifreezes, brake fluids, tanning agents, flavors and preservatives, beauty
products, etc.
 Conversion is thiamine and B6 dependent
 Diet: primarily found in plant foods such as spinach, beets, nuts, legumes, whole grains,
and chocolate

What happens when things go wrong?

 When oxalates absorb systemically, they can bind to calcium and other minerals in the
bloodstream and make crystalline structures. These structures may collect in the renal
tubules and can lead to nephrolithiasis and hyperoxaluria
 Many systems can be affected
 Commonly associated symptoms and conditions include kidney stones, interstitial
cystitis, chronic UTI, and fibromyalgia

Recognize Forms of Oxalate Crystal Disease:

 Primary hyperoxaluria
- High endogenous oxalate because of enzymatic deficiencies
- Leads to renal failure
 Oxalosis
- Occurs with primary hyperoxaluria, renal failure
- Oxalates deposit in tissues of blood, eyes, bones, skin, heart, and more
 Enteric hyperoxaluria
- Intestinal disease (IBD, short bowel)
- Interrupting fat absorption through calcium
- Binding and/or increase permeability
- Leading to excessive oxalate absorption
 Secondary hyperoxaluria
- From overeating high oxalate foods

Less Recognize Form of Oxalate Disorder: Oxalosis with renal failure

Oxalate Toxicity Underlying Causes:

 Antibiotics
 Dietary factors such as high fat and high oxalate diet
 Mold and candida organisms
 High endogenous production (vitamin B6 or B1 deficiency, overconsumption of vitamin
C, genetics)

Oxalates and Testing:

 24-hour urinary oxalate test

  Organic Acids test (look for elevated yeast metabolites, oxalic acid, glycolic acid,
glyoxalic acid, aspergillus, suboptimal B6 status
 Stool test (look for low levels of O. Formigenes, lactobacillus, and other oxalate
degrading bacteria; inflammation; zonulin)
 Mycotoxin test
 Blood work
 Lack of response or intolerance to treatments
 Multiple food intolerances that don’t fit a pattern

How to Treat and Manage Oxalate Toxicity:

Assess the nature of the symptoms

- Kidney stone history or family history?

- Myotoxicity/fungal overgrowth?
- Resistance to treatments? (SIBO, yeast, mold)
- New diet? (Keto, vegan, paleo)
- Multiple food intolerances that don’t follow a pattern?
- Difficulty losing weight?
- Known intolerance to high oxalate foods?

Assess the client’s dietary and supplemental intake of oxalates

- Consult lists that include oxalates in amounts (Harvard list, Oxalate list from Trying
Low Oxalates Facebook group)
- Mark high and moderate foods regularly eaten in red (reduce these)
- Mark low and very low oxalate foods regularly eaten in green (optimize these)
- Mark any foods that are unknowns in yellow as options to introduce into diet
- Pay attention to supplements (multivitamins or protein powders with vegetables,
bee pollen, turmeric, ashwagandha, ginger, wheat grass, soy protein powder,
turmeric, matcha, kelp powder, and more)
- Limit supplemental vitamin C to 500 mg per day
- Limit collagen
- Keep an eye on probiotic and glycine tolerance

Remember:

 Slow and steady wins the race, set a schedule of inclusion, if needed, then reduction
 Get rid of high oxalate supplements first, then diet
 5-10% reduction per week, working towards 50 mg per day
 Can take several months to reduce oxalates appropriately and safely in the diet
 Reducing too quickly can cause “oxalate dumping” from the increasing systemic oxalate
crystals which can be painful and trigger inflammation
Symptoms include:
- Cloudy urine or crystals in urine
- Kidney or bladder
 - Joint or muscle pain
- Eye pain/crystals
- Jaw and tooth pain
- Diarrhea
- Severe anxiety/depression
- Skin eruptions
- Vaginal or oral thrush
- Headaches/dizziness

How to support dumping and oxalate detox?

 Trace minerals and electrolytes with lots of filtered water

- Helps to replete minerals impacted by detox
- Supports kidneys
 Extra citric acid via lemon/lime juice
- Helps to break up oxalate crystals
 Lots of filtered water
 Vitamin K1
- Inhibits formation of crystals
 Biotin
- Oxalates may impact biotin metabolism
 Calcium/magnesium citrate
- Helps to bind oxalate in gut for reduced absorption
- Extra calcium is OK with kidney stones
 Vitamin B6
- Supports metabolism away from oxalate production
- Often deficient in those with oxalate toxicity
- May need to go slowly, can trigger dumping
 Thiamine
- Supports metabolism away from oxalate production
- May need to go slowly, can trigger dumping
 Homeopathic options
- Oxalicum acidum
- MSM eye drops for eye crystals
- Evening primrose oil (found to increase citriuria)

Remember:

 Detoxification can take weeks to years

 Symptoms will come and go, but gradual improvements can occur over time
 Can reduce the supplementation as dumping calms
What low oxalate foods to encourage?

 Animal proteins (eggs, dairy, meet)

 Most fruits
 Many vegetables (squashes, most crucifers, alliums, peppers, bok choy, cucumbers, peas,
radishes, romaine/butter lettuces, mustard greens, etc.)
 Coconut
 Sunflower, pumpkin seeds, pecans, baru nuts (in tolerable amounts)
 White rice, pearled barley
 Lower oxalate beans
 Oils and fats

Remember:

 There may be other food intolerances (starch, histamines, FODMAPs, salicylates, sulfur)
 Tolerance to these might increase or decrease with oxalate detox but may have to look at
clearing other pathways of inflammation
 Building back oxalates is dependent on underlying causes (leaky gut, dysbiosis,
ketogenic or high fat diet, genetic, nutrient deficiencies, mold/yeast)

What are the most common contributors to oxalates? Most and/or yeast

 Treatment can take months or years which can delay reintroduction of foods high in
oxalate
 Practitioners encouraged to take master classes to learn how to effectively treat mold and
yeast
 Watch for herbal treatments high in oxalates
 Always consider biofilms and sinuses

How do we build back gut health?

 Once the problematic actors are cleared out, encourage probiotic, prebiotics, postbiotics,
gut healers. Avoid herbals like slippery elm or demulcents
 Once detoxification has stopped and symptoms have been stable, do a slow increase of
oxalates back into diet (15 mg increments)
 Can maintain minor calcium supplementation to reduce absorption

Mast Cell Activation and Salicylate Intolerance

What are salicylates? Natural chemicals found in many plant-based foods and used as a plant’s
natural insecticide. They have anti-inflammatory effects in the system and are considered
beneficial for pain relief.
Sources of Salicylates:

 Most spices and herbs

 Fruits/vegetables/nuts/seeds/oils
 Skin and body care
 Most herbal supplements
 Aspirin

What is Salicylate Intolerance?

 Inhibition of cyclo-oxygenase in the COX pathway

- Reduction in prostaglandins
- Buildup of leukotrienes
- Increase fluids/swellings
- Release of mast cells, basophils = “allergic” type response

What are Underlying Causes?

 Most common issue in diet salicylate intolerance: impaired detox

 Salicylates are detoxed through Phase II detoxification
- Glycine conjugation
- Glucuronidation
 Other issues that impact these two detox pathways can adversely impact ability to
detoxify salicylates = higher amounts of circulating salicylates

What are Common Symptoms of Salicylate Intolerance?

 Chronic nasal polyps

 Asthma and other lung/bronchial issues
 Chronic GI issues
 Rhinitis
 Urticaria or eczema
 Intolerance to herbal products or antimicrobials

How to Assess for Salicylate Intolerance?

 Did onset occur after environmental exposure?

 On multiple medications that require Phase II?
 Intolerance to aspirin?
 Intolerance to herbal treatments, teas, supplements?
 Lifelong symptoms that patient has been experiencing?
What are Common Underlying Drivers?

 Genetics
 Mycotoxicity
 Yeast overgrowth
 Environmental toxicity
 Occasionally SIBO

Salicylate Intolerance Recommendations

 Eliminate salicylate foods and supplements for 2-3 weeks to calm symptoms and
determine tolerance
- This is a highly restrictive diet and should be recommended with EXTREME
care
 Incorporate foods low in salicylate:
- Any animal protein including red meats, poultry, fish
- Eggs and dairy
- Legumes and most grains
- Cashews
- Vegetables (cabbage, brussels sprouts, celery, peas, leeks, rutabaga, iceberg lettuce,
green beans, potatoes, and more
- Fruits (banana, peeled pear, peeled GD apple, mango, and more)
 If beneficial, reintroduce to ensure salicylates are the issues
- Incorporate fresh herbs and peppermint tea to assess tolerance and if salicylates
are truly the issue
- Supplement and then determine personal threshold of tolerance
 Incorporate supplements (all treatments should be low salicylate!!!)
- Glycine
- Calcium D Glucarate
- P5P
- Low salicylate multivitamin strongly recommended (not a lot of herbals)
- Fish oil

Paleo, AIP, Keto, and Carnivore

Carbohydrate Digestion Overview:

 Carbohydrates are digested using salivary, pancreatic, and brush border enzymes
 Saliva produces salivary amylase
 Pancreas produces amylase
 Bruch border enzymes produce four enzymes to complete CHO digestion
- Sucrase (sucrose into fructose/glucose)
- Lactase (lactose to glucose/galactose)
- Maltase (maltose or maltotriose to glucose)
- Alpha dextrinase (glucose)
What happens when we carbohydrate intolerance?

 Intestinal inflammation which impacts the brush border enzyme activity which can lead
to an inability to complete carbohydrate digestion = carbohydrate intolerance
- Sugar: sugar/sucrose
- Lactose: milk sugars in dairy products
- Maltose: sweet potato, cereals/breads, spelt, broccoli, edamame, more
- Dextrin: corn, tapioca, rice, potato, wheat starches
 Other drivers include dysbiosis with carb loving bacteria such as fungus or mold or
anything else that drives intestinal inflammation

Low Carbohydrate Diets:

 Avoidance or limited starches/sugars

- Some many benefits from a low CHO diet but must have some in the diet to sustain
energy, sleep, and general function
- Limit grains, limit fruits, limit sugar, digestive enzymes? Dependent on client
tolerance!
 Paleo
- No grains, dairy, sugar, legumes
 AIP
- No grain, dairy, sugar, legumes, nightshades, nuts/seeds, eggs
 Keto
- Severe CHO restriction with a high fat/protein ratio
- Fats: 70-80% or 165 g
- Protein: 10-20% or 75 g
- CHO: 5-10% or 40 g
- Might see initial benefits from reducing gut inflammation, dysbiosis, blood sugar
fluctuation, and neural hypersensitivity
- Watch for long term issues (other dysbiosis, sulfur intolerance, oxalate toxicity from
fats, etc.)
- Make sure sulfur pathways are cleared and include lots of electrolytes,
multivitamin/minerals, essential fatty acids, lots of filtered water
 Carnivore (Average observed time is 6-12 months (sustainability is hard unless
benefits are seen, but can be life changing for those whom it works for)
- All meat, all the time – meat/fish
- Dairy/eggs based on tolerance
- Avoid all plants/fibers
- Many using this for MCAS, Lyme, and mold
- Used for a detox when gut has failed
- Very difficult to sustain/tolerate
- Make sure sulfur pathways are cleared and include lots of electrolytes,
multivitamin/minerals, essential fatty acids, and lots of filtered water
- Returning them back to plants: wait for stabilization of symptoms of 2-3 months, then
start with low to moderate FOD/ox/hist/sal plants
 Dietary Management: Severe Food Intolerances

Severe Food Intolerance Part 1

Lymphatic Congestion:

What are lymphatics?

 Secondary circulatory system, lying just underneath the skin

 Removes excess waste from body, filtering bacteria and toxins
 Produces white blood cells and absorbs fatty acids and some proteins and transports
blood
 Maintains fluid balance so tissues don’t swell

When immune system activates, lymph activates and removes debris to the lymph nodes and
ultimately the thoracic duct = healing then happens. However, which chronic immune
stimulation such as MCAS, there is an increase in inflammation in which the lymphatics cannot
remove the toxins or regulate fluid balance which thus leads to congestion, edema, and swelling.
The lymphatics don’t have their own pumping system like the blood does, so they rely on
pulsing of nearby arteries and muscle contractions.

What can we do to support lymphatics?

Self-massage, crystal/jade facial roller, movement, deep diaphragmatic breathing, hold/cold

sensations on back of neck, dry skin brushing, and hydration are all important

Gastrointestinal Inflammation:

What causes gastrointestinal inflammation?

 Mast cells, H1 and H2 receptions in the gut, so with excessive mast cell activation and
histamine stimulation we see increased intestinal inflammation and permeability
 Brush border inflammation
- Reduced diamine oxidase (histamine metabolizer)
- Depleted brush border enzymes (starch intolerance)
- Other food intolerances and leaky gut
 Congested lymphatics
- Cisterna chylii
- Impacts fat and protein digestion
 SIBO, SIFO, parasites, mold, and opportunistic microbes

What can we do to support the GI tract?

 Supportive oral strategies

- Medications
- Supplementations
 - Diet
 Support non-oral strategies
- Abdominal lymphatics
- Castor oil packs on liver to stimulate gut
- Reduce stress in general but especially at mealtimes (encourage conscious eating,
avoid distractions, practice meditation against food fear)
- Encourage daily bowel movements
 Treat underlying driver to inflammation
 Watch for tolerance (single ingredients to begin)

Detoxification Issues:

 Detox support is critical in those with MCAS

 Severe detoxification issues can be related to
- Mold
- Lyme
- Yeast and bacterial overgrowth
- Environmental toxins
- Congested lymphatics
 After eating, all nutrient needs to be processed through the liver, so support the liver!

How do we do support detoxification? Continue to help move the gut!

 Supplementation for liver

- Calcium-D-glucarate
- Glycine
- NAC
- Liposomal glutathione
 Supplementation for gallbladder
- Taurine to support bile synthesis
- Bitters to stimulate bile production
- TUDCA helps to thin and secrete bile
 Binders
- Zeolite, clay, charcoal, chlorella
- Can help with food and supplement tolerance

What can you do non-orally to support detoxification?

 Sweat
- Infrared sauna
- Exercise
- Hot yoga
- Hot Epsom salt baths
 Lymph support
 - Self-massage, crystal/jade facial roller, movement, deep diaphragmatic breathing,
hold/cold sensations on back of neck, dry skin brushing, and hydration are all
important

Reduced Vagal Tone:

The vagus nerve is run by the parasympathetic nervous system and regulates rest and digest. It
transports neurotransmitters made in the gut to the brain and regulates heart rate, blood pressure,
digestion, and stress hormones

Risk factors for reduced vagal tone includes TBI, whiplash, surgeries, chronic stress, bacterial
inflammation, etc.

What can we do to counter reduced vagal tone?

 Deep diaphragmatic breathing

 Meditation before meals
 Alternating hot and cold exposure
 Trigger gag reflex with tongue depression
 Chiropractic therapies
 Vagal stimulation with electrical current

Sinus Inflammation:

 Strong correlation observed with sinus inflammation and food intolerances

 Ear fungus and fluid accumulation can feed into sinus inflammation
 Symptoms include reactivity in head/neck area

What can we do to counter sinus inflammation?

 If mold, check sinuses for MARCONS, staph, fungus, biofilms

 If mold or fungus
- Herbal sprays or hydrosols
 If MARCONS
- Silver or BEG spray
 If chronically congested, assess dairy intakes and environment
 Follow screen time with lymphatic support (crystal or jade roller, self-massage methods)

Severe Food Intolerance Part 2

Environmental Impact:

 Increase in multiple exposures over time is adversely impacting our body’s ability to
regulate
  Environmental exposures can impact multiple pathways including nervous, immune,
detoxification, lymphatic, and digestive systems
 Food intolerance may be driven by one or more of the systems

What can we do?

 Reduce daily exposure

- Organics
- Avoid plastic packaging
- Manage air filter systems
- Dust frequently
- Eliminate household toxins (detergents, soaps, skin care products)
 Assess whether you are better away from home/work/hometown
 Check for local Indoor Environmental Professional for environmental assessment

Excess EMF Exposure:

 All electrical equipment gives off electro-magnetic fields (cell phones, computers, Smart
Meters, electric cars)
 May impact multiple systems
- Hypersensitivity of nervous system
- Skin irritation
- Reduced detoxification
- Circulatory issues
- Lymphatic system interrupted
- Disruption of blood brain barrier
- Associated with Multiple Chemical Sensitivity

What can you do to reduce EMF exposure?

 Visual strain reduction

- Blue light glasses
- Avoid using phone as much as possible
 Improve ergonomics
- Avoid looking down at phone
 Set a timer and take a break every 30 minutes
- Go outside
- Deep breathing exercises
- Facial stretches
 Spend as little time on screen as possible
- Keep electronics out of bedroom
- Turn off router as night
- Reduce skin exposure as much as possible
 Support your own electrical system and ground
- Daily electrolytes
- Tourmaline bracelets
 - Grounding mats

Limbic System Dysregulation:

 Long term stressors or traumas can lead to a chronic fight/flight

 Can lead to overactive immune system

What can we do about limbic system dysregulation?

 Encourage practices that reduce limbic system activation

- meditation with deep breathing
- cognitive behavior theory
- hypnosis
- tapping
- limbic system retraining

Energetic Depletion:

 We rely on balanced electrical and energetic system for our bodies to work efficiently
 Things that draw on the system can lead to imbalance
- Worries and anxieties
- Things that deplete our self-worth
- Traumatic events and inability to communicate needs or beliefs

What can we do for energy repletion?

 Build practices that bring joy

 Take a total media diet
 Reach out to support system
 Grounding exercises
- Yoga
- Time in nature
- Visualized meditations
 Therapy that balances the energy systems of the body
- Reiki
- Healing touch
 Psychedelic Therapies (Lyme disease and mold toxicities)
- Psilocybin
- Bufo
- MDMA
- Ketamine
 Sound/vibrational healing
- Ampcoil
- Binaural beats
 - Sound healing therapy

Food Intolerances:

 Food intolerances can encourage other foods intolerances

 FODMAP intolerance may encourage histamine or starch intolerance
 Histamine intolerance may encourage starch or FODMAP intolerance
 Sulfur intolerance may encourage histamine, starch, FODMAP, and other single food
intolerances
 Oxalate intolerance can impact ALL food intolerance!

Where do we start?

Work your way from the outside in:

 Begin with the top 3: support lymphatics, limbic system restraining, and EMF hygiene
 Environmental clean-up of home, garden, and food
 Energetic grounding and elimination of things that drain you, adding joy
 Detoxification practices, daily
 Vagus nerve supportive exercises
 Assess the gut
 Assess the sinuses
 Have you considered other food intolerances?

Limbic System Retraining: All About Survival

The majority of MCAS clients are going to require limbic system retraining because the
fight or flight response needs to be deactivated or rewired. It is very helpful for those who
cannot expand the diet or are impacted by the environment.

What is the limbic system?

 Area of the brain that manages survival and behavioral response

 Comprised of hypothalamus, amygdala, hippocampus, and thalamus
 Processes emotions, memory, and reinforces behavior
 Links conscious to subconscious- the mind to the body
 Responsible for fight or flight survival response
 Tells the body how to respond to stimuli via hormones, circulation, and neurotransmitters
 Memory of an event is stored in the limbic system for later use
 A consistent input of alarming or traumatic events can create a loop that makes it difficult
to regulate
 Chronic reactivity can lead to immune dysregulation and physical hypersensitivity
What are reasons for limbic system injury?

 Emotional and physical trauma

 Physiological trauma (viruses, injuries, severe dysbiosis)
 Environmental trauma (mold and chemical exposure)

What are symptoms of limbic system injury?

 Stress intolerance
 Anxiousness
 Histamine dysregulation
 Chemical sensitivities
 Reactions to smells, sounds, and visuals
 EMF intolerance
 Food and supplementation intolerance

What is limbic system retraining?

Limbic system retraining programs use a variety of techniques like visualizations, meditation,
positive affirmations, hypnosis, yoga, mindfulness, and other reprogramming techniques to
promote neural plasticity and optimize function.

What are the benefits of limbic system retraining?

 Helps with food, stress, medication, and supplementation intolerance

 Environmental hypersensitivity and MCAS symptom reduction
 Helps with sleep, energy, and mood

What are the downsides of limbic system retraining?

 Cost
 Training and practice time
 Commitment
 Tolerance (rare)

Introducing Foods and Managing Reactions

 Create an agreed upon list together. Let them drive it.

- “What do you want to bring in?”
- “What are you craving the most?”
- Is it a win?
- Veer focus away from foods that you feel fit in within a pattern of reactivity
- Adjust to likes/cravings, deficiencies, previous tolerances
 - Think about well-cooked/blended foods vs raw
 Think about food introduction environment
- Quiet, supportive environment
- Away from activities or responsibilities, low stress
- Prior to introduction, go through grounding and breathing exercises (move from
sympathetic to parasympathetic mode)
- If already doing limbic work, have client do a round before introduction and to do the
steps when reactive
 Baby steps
- Small amounts
- Smell food first
- Small amount in mouth, hold for a few moments, chew, then swallow
- Wait, then move to second bite or stop there
- Stick with one food for 3-5 days before moving on, gradually increase portions
- May need to rotate foods for tolerance

What are ways to reduce reactivity?

 Supplementation (all dependent upon client)

- Zeolite for histamine binding
- Sodium bicarbonate (informs spleen to stop producing immune cells, helps to
mitigate acidity)
- Binders (chlorella, bentonite, activated charcoal, etc.)
 Practices
- Deep breathing
- Lymphatics on area of reactivity (self-massage, jade roller, etc.)
- Get circulation! Exercise, walking, running, etc.
- Cold pack on back of neck (calms vagus nerve reactivity)

Elemental Nutrition: Oral, Enteral and TPN:

What foods should be encouraged for MCAS clients?

 Foods high in DAO

- Pea shoots, micro green, pea sprouts
 Foods that support DAO production
- Olive oil
 Foods high in vitamin C
- Blueberries, broccoli, cauliflower, mango, papaya
 Foods high in quercitin
- Apples, onions, kale, broccoli, blueberries
 Foods high in omega 3 fats
- Fresh fatty fish, hemp, chia, and pumpkin seeds
 Foods high in zinc
 - Fresh animal protein, nuts, and seeds
 Foods high in B6
- Beef liver, darky leafy greens (no spinach!)
 Foods high in B12 and iron
-animal protein and liver

What is elemental nutrition?

 Predigested macronutrients (amino acids, monosaccharides, and fatty acids)

 Doesn’t require active digestion
 Some add micronutrients for additional support
 Administered orally (drinking it), enterally (NG tube, PEG tube, PEJ tube), parenterally
(total parenteral nutrition)

What is the assessment for elemental nutrition?

 Assess for:
- Cachexia
- Continued weight loss leading to BMI <18
- Long term malnourishment via assessment or labs
- Severe caloric restriction below daily needs
- Loss of appetite/interest in food
- Severe reactivity/pain and general intolerance

Oral Elemental Feeding:

 Severe food intolerance, but gut is still working

 Can use supplement alone or with solid food
 Comes as a shake, ice cream, gelatin, etc.
 Many on the market have artificial, intolerable ingredients so it is important to work with
client dependent upon tolerance!
 Best quality and most tolerated
- Absorb Plus Whey or Vegan Unsweetened Vanilla Crème Brulee
- Functional Medicine Formulations Elemental Heal
- Kate Farms
- Neocate Splash (typically for children)
- Integrative Therapeutics Physician’s Elemental Formula

When is surgical elemental nutrition necessary such as PEG, PEJ, or TPN?

 Complete intolerance of any oral nourishment to sustain basic needs

 Needs to be referred to a gastroenterologist to discuss options
 Placement is done outpatient (enterally) and inpatient (total parental nutrition)
What is your job as the dietitian?

 Communicate with medical team, starting with PCP

 Request referral to gastroenterology ASAP
 Assessment/recommendations/concerns IN WRITING to PCP or GI doctor
 Advocate for preferred formula

How to determine enteral or parenteral? This is the GI doctor’s decision.

 Start with enteral always

 PEJ or PEG preferable (NG tube can be too irritable)
 Tolerance is surprisingly food with PEJ
 TPN is all else fails

Monitoring of Client:

 May need to community with assigned RDN/tech

 Start with more frequent feedings using smaller amounts
 Avoid boluses initially
 Can increase frequency and amounts as tolerate
 May take days or weeks to get to needed kcals
 Once system has adjusted and calmed down, can start adding in small amounts of oral
intake
 Remove tube once oral intake is up to speed, can shift to oral elemental formulas for kcal
management
 Great time to start limbic system retraining!
- If immune system is in sympathetic mode, retraining can help client be in a better
position to tolerate the reintroduction of foods!
 Initial Office Visit and Assessment
1. Prior to appointment, collect as much information as possible.
- Assess questionnaire prior to initial appointment
- Testing and diagnostics that have been completed
- Detailed health history and timeline
2. Once in office, establish rapport and build assessment towards diet (don’t
overwhelm the client right away).
- Don’t just focus on current symptoms or dietary restrictions, look at the twists and
turns of what led them to this point
- SHEDD assessment, look particularly for traumas, lots of antibiotics, and
environmental changes
- Assess the story so you can start to build theory
3. Assess treatment history and comorbidities.
- What other treatments have they done
- What has helped? What has made things worse?
- Supplement tolerance/efficacy
- Medication tolerance/efficacy
- Other modalities?
- Other comorbidities such as dysbiosis, mold, Lyme, hypothyroid, PTSD, trauma?
4. Assess symptoms.
- Head/neck: sinus, swelling, sore throat, ear pain
- Lung: SOB, asthma
- Digestive: Gas, bloat, constipation, diarrhea, N/V
- Hormonal: endometriosis, worsening PMS
- Genito-urinary: nocturia, vulvodynia, urinary frequency
- Skin: urticaria, eczema, cystic acne
- Sleep: insomnia
- Stress intolerance
5. Make sure baseline needs are being met.
- Assess for deficiencies and treat first!
- Assess for low weight or excess/continued weight loss
- Capable of dietary expansion
- Supplement or expand diet, as tolerated or PRN
- Consider elemental formulas, PRN
6. Assess dietary elimination history.
- Known reactants
- Diets tried in the past/present
7. If no elimination history…
- Assess diet and known reactants
- Consider symptoms, known diagnosis, suspected issues based on history, elimination
strategies
- Make other recommendations outside of the diet and hold on dietary elimination until
more information is available
8. Once you have all your data points, come up with a plan!
- Explain your thought process and retell their story to them
 - Work way towards diet, assess ability/need to make dietary changes
- Recommend food/supplement/elemental nutrition to fill in nutritional gaps as
appropriate
- Educate on stabilizations OTCs, supplements, testing as need, and practices that
support finding in SHEDD assessment
- Diet: EXPANSION BEFORE ELIMINATION
- Monthly sessions to assess efficacy/tolerance

Return Office Visit and Assessment

If client comes back feeling worse…

 What foods did they inadvertently increase on this new diet?

- Look for nature of symptoms increased
- Look for patterns in any foods increased
 If no increase in foods, what might they have lost
- Sulfur?
- Phytonutrients?
- Fiber from plants?
 Supplements or Rx added or subtracted?
 Lifestyle changes?
- More stressed?
- New environment?

How to manage:

 Return them to previous diet as baseline

 Let rest for a while
 Do they want to move forwards with another elimination if another food intolerance is
suspected?
 Do they want to work on other calming strategies first?
 Continue to make appropriate treatment recommendations based on new information
 Testing, dietary changes, and supplementation as needed
 Remind them that all roads are leading back to dietary expansion!
 Overview:
Stabilize First!

 OTC: H1/H2 trials

 Rx: Cromolyn, Ketotifen, LDN, Hydroxyzine, Benzos, etc.
 Supplementation: Quercitin, SPM, PEA, etc.
 Based on patient preference and tolerance
 Look for tolerance and efficacy

Make sure baseline needs are being met

 Dietary expansion?
 Need for supplementation, elemental support, enteral support?

Identify triggers and assess underlying causes

 Assess previous history of tolerances/intolerances

 Assess other known intolerances
 Use SHEDD assessment to determine other triggers and underlying causes

Food Elimination Review:

Remember that food elimination is way to stabilize symptoms and identify pathways that are
driving inflammation and may even help expand the diet.

 Be observant to current food intolerance and observe any remaining symptoms that could
indicate other pathways are being impacts
 Start with a low histamine diet to determine tolerance/efficacy
 Consider other food chemical intolerances

With severe food intolerance…

 May need oral or enteral formulas
 Consider the Top 10 list to help you consider the most likely underlying drivers of the
food intolerance and practices to recommend to client
 Food introduction should be slow and steady
- Agreed upon list
- Quiet atmosphere
- One food at a time
- Swallow when ready
- Address food dear
- Limbic system retraining rounds and steps
- With reaction, consider bicarbonate or binder
 Final Advice:

 Don’t get overwhelmed – intuition will grow with time

 Remain flexible in your approach – dogmatic thinking will get you

nowhere!

 If they tolerate it, they can eat it

 Remind you client that they could react to anything you

recommend, be honest!

 Practice patience, perseverance, and encouragement!

 Always keep your eye on the next steps

The most important goal you as the dietary manager should be

considering when working with an MCAS client is EXPANDING THE

DIVERSITY OF THE DIET!