Systemic Mastocytosis (SM)

Systemic mastocytosis is a rare hematological disease characterized by the overproliferation of mast cells, white blood cells that originate in the bone marrow, throughout the connective tissues of multiple organ systems, including the liver, spleen, bones, lymph nodes, lungs, and digestive system.¹

Mast cells are activated by environmental triggers, including insect stings, animal bites, temperature changes, minor traumas, surgeries, vaccines, stress, anxiety, inhaled chemicals, certain medications, and ingested foods or additives.^1,2 When allergens bind to mast cells, the activated mast cells release inflammatory chemical mediators, such as histamine, heparin, cytokines, and growth factors.³ These mediators promote angiogenesis and vasodilation to help the immune system fight off the perceived threat. In addition, mast cells regulate functions related to macrophages, fibroblasts, endothelial cells, T and B cells, dendritic cells, and epithelial cells.⁴ 

Recommended Diets for Systemic Mastocytosis

Because histamine and other inflammatory chemical mediators result in widespread symptoms of systemic mastocytosis, symptoms may be improved by limiting the amount of histamine within the body and reducing exposure to potential food triggers through 2 recommended diets. 

Low-histamine diets and elimination diets are recommended for individuals with mast cell disorders including systemic mastocytosis. While these diets are not specific, they provide guidelines for people with systemic mastocytosis to follow with regards to their diet and nutrition since each individual reacts differently to different foods.² 

Low-Histamine Diets

Low-histamine diets restrict the ingestion of foods that are high in histamine or that may increase mast cell release of histamine and add to the existing levels of histamine circulating throughout the body. Some individuals with systemic mastocytosis may also have a reduced concentration of enzymes that break down histamine contained in foods or a tendency to absorb more histamine from food, complicating the excessive release of histamine from overproliferate mast cells.² 

Foods that are spoiled, aged, overly processed, or fermented often contain more histamine than fresh foods.² Fermented foods and beverages such as sauerkraut, yogurt, kimchi, kefir, tempeh, natto, miso, kombucha, sourdough bread, pickled foods, and alcohol are also high in histamine.⁵ 

The amount of histamine contained in aged cheeses is affected by the temperature at which they are stored, with less histamine found in cheeses stored at lower temperatures. ​​Aged cheeses such as cheddar, Swiss, Parmesan, and Gouda are considered to be higher in histamine, while cottage cheese, mozzarella, and ricotta have lower amounts of histamine.⁶ 

People with systemic mastocytosis should opt for meat that is fresh instead of preserved, packaged, or smoked. The cooking method for meat changes the amount of histamine within it. For example, boiling meat decreases histamine level, while grilling increases it.⁶ 

Certain legumes and tree nuts such as peanuts, chickpeas, kidney beans, almonds, hazelnuts, walnuts, Brazil nuts, macadamia nuts, pecans, and pistachios are known to trigger allergic reactions.^6,7 Many tree nuts contain amines (histamine is an amine), which may increase the overall histamine burden within the body.⁷

Citrus fruits such as lemons, limes, and oranges can trigger the release of histamine but are not inherently high in histamine themselves.⁶ Other foods that trigger the release of histamine, called histamine liberators, include milk, shellfish, eggs, kiwi, pineapple, strawberries, papayas, plums, bananas, chocolate, vinegar, wheatgerm, walnuts, Brussels sprouts, seafood, avocados, alcohol, and tomatoes (which are also inherently high in histamine).^8,9 

Systemic mastocytosis ranked fifth in conditions aggravated by consuming nightshade vegetables.¹⁰ Some nightshades such as eggplant and tomato are higher in histamine.⁸ Other nightshades like white potatoes and peppers have less histamine but may still trigger a histamine reaction because they contain alkaloids such as solanine and capsaicin. Spicy foods containing a large amount of hot peppers with capsaicin may trigger a reaction in individuals with systemic mastocytosis.^11,12

Elimination Diets

Elimination diets help individuals with systemic mastocytosis determine which foods trigger a reaction. With the help of a registered dietitian, people with systemic mastocytosis begin with a very limited diet consisting of foods that do not cause a reaction. They then slowly reintroduce a specific food one by one while keeping a food diary to record any symptoms that occur after eating a particular food. This allows potential food triggers to be permanently eliminated from the diet, which in turn reduces the likelihood of an allergic reaction after eating.²

In general, people with mast cell diseases react more frequently to monosodium glutamate (MSG), shellfish, alcohol, food preservatives, artificial food dyes and flavoring additives, pineapples, any products made from tomatoes, and chocolate. This is not an exhaustive list, as each person has unique sensitivities. While some people may react to these substances, others may not.² 

Patient Experiences 

The Mastocytosis Society conducted a patient survey that included questions about diet and nutrition. Of the survey participants, 382 answered the diet and nutrition questions. Only 10.7% had been referred to a dietitian by their physicians. Physicians and dietitians/nutritionists recommended low-histamine diets to 12% and 5.8% of these patients, respectively. Approximately 34.6% of survey participants tried elimination diets and 24.6% followed a low-histamine diet. Crossover between the 2 diets occurred, with 14.4% of patients on a low-histamine diet having also tried an elimination diet. Around 51.1% of patients on a low-histamine diet reported symptom improvement, while 19.1% did not and 29.8% were unsure.¹³ 

Medication Interactions With Food

Since there are 5 different subtypes of systemic mastocytosis and a variety of treatments for each one, each person may have specific dietary restrictions or recommendations depending on their medications to optimize health and nutrition, improve symptoms, and ensure that treatments are successful.

Patients who are undergoing treatment with midostaurin for systemic mastocytosis should eat basil and broccoli and avoid bell peppers, green beans, and black seed nutritional supplements.¹⁴

Medications to Avoid

Certain medications such as nonsteroidal anti-inflammatories, opioids, aspirin, certain antibiotics in the fluoroquinolone family, and muscle relaxants may trigger reactions in people with systemic mastocytosis, so avoidance of these medications is advised. Morphine, hydromorphone, and sedatives like propofol and benzodiazepines can trigger release of histamine and cause a vasodilatory effect.^1,15

Recommended Supplementation

Multivitamin and mineral supplementation is recommended. Quercetin, an antioxidant, has shown its ability to reduce mast cell activity in studies. Vitamin C is commonly reported to help people with systemic mastocytosis, although no studies have confirmed this.²

References

1. Systemic mastocytosis. MedlinePlus. Updated August 18, 2020. Accessed April 20, 2022.
2. Nutrition. The Mast Cell Disease Society. Accessed April 20, 2022.
3. Amin K. The role of mast cells in allergic inflammation. Respir Med. 2012;106(1):9-14. doi:10.1016/j.rmed.2011.09.007
4. Krystel-Whittemore M, Dileepan KN, Wood JG. Mast cell: a multi-functional master cell. Front Immunol. 2016;6:620. doi:10.3389/fimmu.2015.00620
5. Mohammed M. Kombucha, kimchi and yogurt: how fermented foods could be harmful to your health. The Conversation. November 13, 2019. Accessed April 20, 2022.
6. Foods high in histamine. WebMD. Accessed April 20, 2022.
7. Leong K. Low histamine nuts and seeds. Histamine Doctor. June 16, 2021. Accessed April 20, 2022.
8. Richards L. How the low histamine diet works and what to eat. Medical News Today. June 11, 2020. Accessed April 20, 2022. 
9. Torrens K. What is a low-histamine diet? BBC Good Food. July 24, 2020. Accessed April 20, 2022.
10. Nightshades (Solanaceae vegetables) as an aggravating factor across conditions. StuffThatWorks. Accessed April 20, 2022.
11. Systemic mastocytosis – symptoms and causes. Mayo Clinic. November 20, 2020. Accessed April 20, 2022.
12. Is bell pepper high in histamine? Food is Good (FIG). Accessed April 20, 2022. 
13. Russell N, Jennings S, Jennings B, et al. The Mastocytosis Society survey on mast cell disorders: part 2—patient clinical experiences and beyond. J Allergy Clin Immunol Pract. 2019;7(4):1157-1165.e6. doi:10.1016/j.jaip.2018.07.032
14. Which 3 foods to avoid for systemic mastocytosis? Addon. March 23, 2021. Accessed April 20, 2022. 
15. Mast cell degranulation. ScienceDirect Topics. Accessed April 20, 2022.

---

Maria Arini Lopez, PT, DPT, CSCS, CMTPT, CIMT

Maria Arini Lopez, PT, DPT, CSCS, CMTPT, CIMT is a freelance medical writer and Doctor of Physical Therapy from Maryland. She has expertise in the therapeutic areas of orthopedics, neurology, chronic pain, gastrointestinal dysfunctions, and rare diseases especially Ehlers Danlos Syndrome.