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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 21 of 21. This is the beginning of the thread.
Posted by cubbybear on September 24, 2004, at 12:55:16
The test info that is available on safety of Parnate/Nardil with various cheeses doesn't mention some of my favorites. I'd like to hear from any MAOI user who can say with assurance that small quantities of MONTEREY JACK, GOUDA, EDAM,and/or NOKKEL OST were OK for them.
Thanks for any info.
Posted by gardenergirl on September 24, 2004, at 23:07:25
In reply to Parnate and cheese, posted by cubbybear on September 24, 2004, at 12:55:16
Can I add Havarti to the list? I recently had to put it out of sight when I had guests here. I would have loved to have been able to have some...
gg
Posted by Larry Hoover on September 25, 2004, at 8:16:19
In reply to Parnate and cheese, posted by cubbybear on September 24, 2004, at 12:55:16
> The test info that is available on safety of Parnate/Nardil with various cheeses doesn't mention some of my favorites. I'd like to hear from any MAOI user who can say with assurance that small quantities of MONTEREY JACK, GOUDA, EDAM,and/or NOKKEL OST were OK for them.
>
> Thanks for any info.I don't have any personal experience to offer you, but jack, gouda and edam (can't find nokkel ost) are on the high tyramine list. Really, any named varietal cheese that you can think of is high tyramine. It's an innate part of what makes it into cheese. The exceptions *may* include members of what are called "fresh cheeses", where the curds are not aged before consumption, e.g. ricotta, marscapone, cottage cheese. Even those should be used with caution. Slightly more risky are formed curd cheeses like mozzarella. Tyramine sensitivity is an individual characteristic. The amount that puts you into crisis might be a small fraction of what another person tolerates without effect.
Lar
Posted by Larry Hoover on September 25, 2004, at 8:18:34
In reply to Parnate and cheese, posted by cubbybear on September 24, 2004, at 12:55:16
Posted by Larry Hoover on September 25, 2004, at 8:19:43
In reply to What about Havarti?, posted by gardenergirl on September 24, 2004, at 23:07:25
> Can I add Havarti to the list? I recently had to put it out of sight when I had guests here. I would have loved to have been able to have some...
>
> ggThis website says you could have had some....
http://devweb3.vip.ohio-state.edu/Materials/PDFDocs/nut-diet/nut-other/low-tyr.pdf
Lar
Posted by cubbybear on September 25, 2004, at 8:29:31
In reply to Re: correction....mozzarella probably excluded too (nm) » cubbybear, posted by Larry Hoover on September 25, 2004, at 8:18:34
Absolutely NOT true--many MAOI users, including myself, have been able to enjoy a pizza with mozzarella cheese (with precautions about adding other cheeses or certain meats) or plain mozzarella itself.
Posted by ron1953 on September 25, 2004, at 11:27:56
In reply to Parnate and cheese, posted by cubbybear on September 24, 2004, at 12:55:16
I started Parnate upon the suggestion of a friend who's a Psychiatrist. When I asked him about the dietary restrictions, he informed me that NONE of his MAOI users ever experienced a hypertensive crisis. He did recommend monitoring my BP and having a small supply of Procardia on hand just in case. When I did my research on the dietary restrictions, I found that the list was totally out of date and mostly incorrect. I've had absolutely no problems. Not only do I enjoy pizza with mozzarella cheese, I have it with pepperoni! I've eaten small quantities of aged cheese with no problem. My understanding is that the amount of tyramine eaten is what's critical. An example is the amount of pepperoni (supposedly a total no-no) I eat on pizza doesn't contain enough tyramine to cause a reaction. Eating a whole stick of pepperoni probably wouldn't be a good idea. I haven't changed my diet one bit but I keep the tyramine thing in mind at all times. If you haven't already gotten a medical alert bracelet, please do. Demeral will kill you.
Posted by King Vultan on September 25, 2004, at 11:28:49
In reply to Re: correction....mozzarella probably excluded too » Larry Hoover, posted by cubbybear on September 25, 2004, at 8:29:31
> Absolutely NOT true--many MAOI users, including myself, have been able to enjoy a pizza with mozzarella cheese (with precautions about adding other cheeses or certain meats) or plain mozzarella itself.
The information available on mozzarella seems to be somewhat ambiguous. On the one hand, the work originally done by Shulman, et al, in 1989 shows the tyramine content of mozzarella to be 2.4 mg per 15 g serving. To my way of thinking, that seems like kind of a lot. The exact amount of tyramine that is needed to precipitate a hypertensive crisis varies according to the individual, dosage, and drug, but in a study in "Clinical Advances in Monoamine Oxidase Inhibitor Therapies", the median effective dose of tyramine (in capsules) needed to raise systolic BP by 30 points was 8 mg for 12 subjects on 20 mg of Parnate. The median amount needed to raise BP a similar amount for 6 people on 60 mg Nardil was 33 mg. Contrast this with a median amount of 428 mg of tyramine needed to raise systolic BP 30 mm Hg for 56 unmedicated subjects.OTOH, I also have the results of the pizza analyses performed by Drs. Shulman and Walker in 1998, where the tyramine content of mozzarella cheese was retested, and the amount was a mere 0.5 mg per 30 gram serving. The amount of tyramine measured in half a Pizza Hut medium pizza with double cheese and pepperoni was a completely harmless 0.0628 mg total, that in a sample of pizza toppings (the crust was not included) with a mass of 136.5 grams. The authors do caution that this doesn't necessarily mean that all pizzas are safe, as for instance, some gourmet pizzas may contain cheeses of a more aged variety. I also have concerns about pepperoni variations between different chains. I have read two anecdotes of different people experiencing hypertensive crises eating pepperoni pizza at small, local pizza joints while on Parnate.
Todd
Posted by Larry Hoover on September 25, 2004, at 12:42:52
In reply to Re: correction....mozzarella probably excluded too » Larry Hoover, posted by cubbybear on September 25, 2004, at 8:29:31
> Absolutely NOT true--many MAOI users, including myself, have been able to enjoy a pizza with mozzarella cheese (with precautions about adding other cheeses or certain meats) or plain mozzarella itself.
Erring on the side of caution, is all. I know how mozzarella is made, and that's what led me to include it in safe cheeses in my first list. When I came across it listed in a forbidden cheese group, I certainly didn't want to have misled someone into a hypertensive crisis.
Dose is always the critical factor, and individual variability in sensitivity to tyramine varies dramatically. Being safe trumps food variety, unless you are willing to do some experimentation. I didn't want to have someone coming back with, "Larry Hoover said it was okay."
Lar
Posted by Larry Hoover on September 25, 2004, at 12:53:35
In reply to Re: Mozzarella and tyramine studies, posted by King Vultan on September 25, 2004, at 11:28:49
> OTOH, I also have the results of the pizza analyses performed by Drs. Shulman and Walker in 1998, where the tyramine content of mozzarella cheese was retested, and the amount was a mere 0.5 mg per 30 gram serving. The amount of tyramine measured in half a Pizza Hut medium pizza with double cheese and pepperoni was a completely harmless 0.0628 mg total, that in a sample of pizza toppings (the crust was not included) with a mass of 136.5 grams. The authors do caution that this doesn't necessarily mean that all pizzas are safe, as for instance, some gourmet pizzas may contain cheeses of a more aged variety. I also have concerns about pepperoni variations between different chains. I have read two anecdotes of different people experiencing hypertensive crises eating pepperoni pizza at small, local pizza joints while on Parnate.
>
> ToddHere are some Shulman abstracts. Thanks for bringing critical information to light. There is so much misinformation in the "standard medical wisdom". I don't remember seeing draft (or tap) beer as being restricted, or tofu, for that matter.
Lar
J Clin Psychiatry. 1999 Mar;60(3):191-3.
Comment in:
J Clin Psychiatry. 2000 Feb;61(2):145-6.Refining the MAOI diet: tyramine content of pizzas and soy products.
Shulman KI, Walker SE.
Department of Psychiatry, University of Toronto, Sunnybrook Health Science Centre, Ontario, Canada.
BACKGROUND: Continuous refinement of the monoamine oxidase inhibitor (MAOI) diet has resulted in much reduced and simplified recommendations that attempt to balance safety and practicality. In the spirit of evidence-based practice, dietary restrictions should be based on carefully documented case reports and valid tyramine analyses. Residual concerns have focused on combination foods such as pizza and a variety of soy products. We determined the tyramine content of pizzas and a variety of soy products in order to refine dietary recommendations for use with MAOIs. METHOD: High-pressure liquid chromatography analysis of tyramine content was performed on a variety of pizzas, soy sauces, and other soybean products. A tyramine level of 6 mg or less was considered safe. RESULTS: No significant tyramine levels were found in any of the pizzas, including those with double pepperoni and double cheese. Marked variability was found in soy products, including clinically significant tyramine levels in tofu when stored for a week and high tyramine content in one of the soy sauces. CONCLUSION: Pizzas from large chain commercial outlets are safe for consumption with MAOIs. However, caution must be exercised if ordering pizzas from smaller outlets or gourmet pizzas known to contain aged cheeses. All soybean products should be avoided, especially soy sauce and tofu. Individualized counseling and continuous surveillance of compliance are still essential.
J Clin Psychopharmacol. 1996 Oct;16(5):383-8.
Comment in:
J Clin Psychopharmacol. 1997 Jun;17(3):226-7; author reply 227-8.
J Clin Psychopharmacol. 1997 Jun;17(3):227; author reply 227-8.Tyramine content of previously restricted foods in monoamine oxidase inhibitor diets.
Walker SE, Shulman KI, Tailor SA, Gardner D.
Department of Pharmacy, Sunnybrook Health Science Centre, University of Toronto, Ontario, Canada.
Traditional monoamine oxidase inhibitors (MAOIs) remain an important class of drugs for a variety of psychiatric conditions, including depressive illnesses, anxiety, and eating disorders. It was the objective of this study to refine the MAOI diet by determining the tyramine content of a variety of untested and "controversial" foods that continue to appear on MAOI diet-restricted food lists. A secondary objective of the study was to evaluate the effect of freshness on the tyramine content of some foods. Fifty-one food samples were evaluated for tyramine content by liquid chromatography. Food samples included a selection of sausages, beverages, sliced meat products, including chicken liver, and some fruits, including raspberries, bananas, and banana peels. Foods that were found to have dangerously high concentrations of tyramine (> or = 6 mg/serving) included chicken liver aged 9 days (63.84 mg/30 g), air-dried sausage (7.56 g/30 g), soy sauce (0.941 mg/ml), and sauerkraut (7.75 mg/250 g). Of the foods analyzed in this study, only those with high tyramine content per serving should continue to be absolutely restricted. All other foods are either safe for consumption or safe in moderation. The data provided should be combined with the data from other similar analytical studies to develop a list of foods that should be absolutely restricted. A more accurate list of restricted foods may enhance patient dietary compliance.
Can J Psychiatry. 1997 Apr;42(3):310-2.Tap (draft) beer and monoamine oxidase inhibitor dietary restrictions.
Shulman KI, Tailor SA, Walker SE, Gardner DM.
Department of Psychiatry, University of Toronto, Ontario.
OBJECTIVE: Traditional monoamine oxidase inhibitors (MAOIs) continue to play an important role in the management of a wide variety of clinical conditions. Accordingly, a practical and safe approach to MAOI dietary restrictions remains an essential component of patient management. METHOD: In an effort to refine MAOI dietary recommendations, we report a case of hypertensive crisis following the consumption of a modest amount of tap beer. RESULTS: A well-documented case report involving tap (draft) beer consumed while on an MAOI supports an earlier study, which recommended that all tap beers be restricted on MAOI diets. The 2 cases were remarkably similar in terms of the offending substance, quantity consumed, and subsequent reaction. CONCLUSIONS: As a result of recent tyramine analyses and 2 well-documented case reports, all tap (draft) beers should now be absolutely restricted on MAOI diets because they represent a very significant risk at modest levels of consumption.
Posted by gardenergirl on September 25, 2004, at 19:32:06
In reply to Re: What about Havarti? » gardenergirl, posted by Larry Hoover on September 25, 2004, at 8:19:43
Oh joy of joys! That was truly the first time I felt deprived of cheese...looking at that Havarti. Yeah, and two ounces is a decent size amount.
Incidentally (haven't read rest of thread yet, so this might be redundant) I eat fresh mozzarella a lot. Mmm, with tomato slices, fresh basil, olive oil, and some good crusty bread.
yummy!
Thank you Lar! I will definitely bookmark that page. And I know someone who might be interested in the idea of being able to eat 4 oz. of liverwurst.
Warmly,
gg
Posted by gardenergirl on September 25, 2004, at 19:40:36
In reply to Re: What about Havarti? » gardenergirl, posted by Larry Hoover on September 25, 2004, at 8:19:43
I appreciate your concern due to individual's responses may vary. That's why I think it's always best to be very conservative at first, and then try the items that have been questioned slowly and when you are comfortable. That's what I did. The list on the link you posted seems good, but then it also says no bananas, and that is supposed to be banana peels, not the fruit itself. Also, chocolate and caffeine are supposed to be in moderation based on the majority of what I've read.
But then you have to kind of take all the research and synthesize into your own plan based on what makes sense, what is seen most often, and your own comfort level.
Always an interesting topic.
gg
Posted by Ilene on September 25, 2004, at 21:01:32
In reply to Re: What about Havarti? » gardenergirl, posted by Larry Hoover on September 25, 2004, at 8:19:43
> > Can I add Havarti to the list? I recently had to put it out of sight when I had guests here. I would have loved to have been able to have some...
> >
> > gg
>
> This website says you could have had some....
>
> http://devweb3.vip.ohio-state.edu/Materials/PDFDocs/nut-diet/nut-other/low-tyr.pdf
>
> Lar
>
That website is wrong, wrong, wrong. I don't know whether it's wrong about Havarti, but it's wrong about yogurt, sour cream, and processed American cheese. All of those are okay to eat. I eat yogurt and American cheese regularly.
Posted by Larry Hoover on September 26, 2004, at 8:04:20
In reply to Re: What about Havarti?, posted by Ilene on September 25, 2004, at 21:01:32
> > > Can I add Havarti to the list? I recently had to put it out of sight when I had guests here. I would have loved to have been able to have some...
> > >
> > > gg
> >
> > This website says you could have had some....
> >
> > http://devweb3.vip.ohio-state.edu/Materials/PDFDocs/nut-diet/nut-other/low-tyr.pdf
> >
> > Lar
> >
> That website is wrong, wrong, wrong. I don't know whether it's wrong about Havarti, but it's wrong about yogurt, sour cream, and processed American cheese. All of those are okay to eat. I eat yogurt and American cheese regularly.I think the problem we're seeing here isn't one of foods themselves. We want to be able to form hard and fast rules to guide food selection. Unfortunately, Mother Nature does things differently.
Various microbes that can infect food will transform certain amino acids, among other molecules. Tyramine is an amino acid byproduct. Those transformations will often produce intensely flavoured foods. When the infecting microbe is well-chosen, the resultant food will be highly sought after. Consider the difference between authentic Parmesan and the grey sodden smelly mass that forms on too long refrigerated cottage cheese. Which one is the appetizing one? But Parmesan takes much longer to produce, because the microbes tranforming it are rather slow workers. Really, Parmesan is a fluke of nature. Cheesemakers in Parma got lucky that the local microbes imparted a special je ne sais quoi to their cheese while in storage. If it had spoiled instead, those cheesemakers would have become carpenters or something else. Ya know?
In reading the literature that I have been able to access, I see that food products that we call by a particular name (e.g. mozzarella cheese, or tofu) may have substantially different chemical characteristics. Tofu that has aged as little as nine days may have huge tyramine content, whereas fresh tofu would likely have none. It all depends on those little microbe fellas, which are in the air, on surfaces, on our skin, in our breath.....just waiting to land on moist nutritious surfaces.....food. Even the same company's mozzarella might vary over time, let alone vary when compared to the stuff made across town.
I think that a dangerous attitude may develop if one presumes that e.g. "American cheese" is ALWAYS safe. Your next slice may have been colonized by tyramine-producing critters. One reference described "air-dried sausage" as having extreme tyramine content. Well, pepperoni is supposed to be an air-dried sausage, as is salami, summer sausage, and so on. That doesn't mean that modern food production techniques will prevent tyramine formation, but based on the recent analyses, it looks like that particular character is largely blocked. What happens if you get a couple pieces of real pepperoni on a pizza, and it happens to also have some mozzarella which was grated on a less than perfectly clean grater, and held for a couple of days before use?
Anybody using Nardil or Parnate or any other drug associated with tyramine restriction should become fully aware of the symptoms of hypertensive crisis, and should carry medication to forestall the most serious effects of hypertensive crisis while seeking emergency care.
Relying solely on the selection of food types is foolhardy. One paper I read mentioned that certain soy sauces are very high in tyramine. I know for a fact that soy sauce is added to restaurant foods, particularly sauces, without that fact being disclosed. All it takes is a few miligrams of tyramine. Eating something once without adverse effects is not a guarantee that eating it again will lead to the same result.
So, caution is always warranted. Recognizing where the risks are most likely to be found is only part of the puzzle. Being prepared for the surprises is the other part.
Individual differences in tyramine sensitivity are also confusing the risk assessment. I know a guy on Parnate who eats old cheddar. He gets a buzz, but he likes that buzz. The same behaviour would kill someone else, though. What works for you applies only to you.
Lar
Posted by Ilene on September 26, 2004, at 22:48:57
In reply to Re: What about Havarti? » Ilene, posted by Larry Hoover on September 26, 2004, at 8:04:20
When I started taking an MAOI I was worried about the diet, but the more I read, the less worried I got. The most authoritative sources reported the fewest food restrictions.
What relaxed me was learning that 80% of reactions are due to aged cheese. I eat fresh but not aged cheese--I won't eat aged cheese under any circumstances, even though I used to eat it every day. I'm not going to worry about a food that was reported to trigger a reaction back in 1963.
I've cautiously added certain foods. For example, I didn't eat soy sauce. Later I started adding small amounts to a recipe. Now I eat any amount I want. I use Kikkoman at home because it tests low in tyramine content, but I eat in Chinese and Japanese restaurants with no problem.
I wear a medical alert necklace and carry nifedipine as backup.
I think MAOIs are underprescribed. I'm finally on a med regimen that works, after trying about a dozen drugs. I think too many people, doctors as well as patients, are turned off by the perception of onerous food restrictions.
Posted by Larry Hoover on September 28, 2004, at 8:07:26
In reply to MAOI diet » Larry Hoover, posted by Ilene on September 26, 2004, at 22:48:57
> When I started taking an MAOI I was worried about the diet, but the more I read, the less worried I got. The most authoritative sources reported the fewest food restrictions.
>
> What relaxed me was learning that 80% of reactions are due to aged cheese. I eat fresh but not aged cheese--I won't eat aged cheese under any circumstances, even though I used to eat it every day. I'm not going to worry about a food that was reported to trigger a reaction back in 1963.
>
> I've cautiously added certain foods. For example, I didn't eat soy sauce. Later I started adding small amounts to a recipe. Now I eat any amount I want. I use Kikkoman at home because it tests low in tyramine content, but I eat in Chinese and Japanese restaurants with no problem.
>
> I wear a medical alert necklace and carry nifedipine as backup.
>
> I think MAOIs are underprescribed. I'm finally on a med regimen that works, after trying about a dozen drugs. I think too many people, doctors as well as patients, are turned off by the perception of onerous food restrictions.I agree 100%. I also fully support your decisions, as you carry both a medical alert medallion (necklace or bracelet) and emergency drug supply. No different than someone with a severe allergy to peanuts with a similar warning device and an Epipen.
I didn't realize, when I first posted, how flawed the "general wisdom" actually was. I'm glad that reanalyses of foods have occurred. A big part of my work is analytical chemistry, and modern equipment makes equipment from 20 years ago look like it came from the stone age, the changes are so dramatic.
The only warning that I might add is more general. You don't know how the food you eat has been handled after it was produced. Safe foods can be contaminated by bacteria, and become unsafe. High protein foods are most likely to lead to tyramine contamination. That's why cheese, soy products, and meats are so prominent in the lists of foods of concern.
Lar
Posted by SLS on September 28, 2004, at 9:27:05
In reply to Re: MAOI diet » Ilene, posted by Larry Hoover on September 28, 2004, at 8:07:26
Hi Larry.
You are just so cool - I mean accurate - I mean cool.
:-)
- Scott
> I didn't realize, when I first posted, how flawed the "general wisdom" actually was. I'm glad that reanalyses of foods have occurred. A big part of my work is analytical chemistry, and modern equipment makes equipment from 20 years ago look like it came from the stone age, the changes are so dramatic.
>
> The only warning that I might add is more general. You don't know how the food you eat has been handled after it was produced. Safe foods can be contaminated by bacteria, and become unsafe. High protein foods are most likely to lead to tyramine contamination. That's why cheese, soy products, and meats are so prominent in the lists of foods of concern.
Posted by cubbybear on September 28, 2004, at 11:56:46
In reply to Re: MAOI diet » Ilene, posted by Larry Hoover on September 28, 2004, at 8:07:26
A big part of my work is analytical chemistry, and modern equipment makes equipment from 20 years ago look like it came from the stone age, the changes are so dramatic.
Is there any possibility that a person without your background can obtain and use equipment at home to test for tyramine in foods?!? Imagine how revolutionary that would be for MAOI users and doctors.
Posted by Larry Hoover on September 28, 2004, at 12:40:20
In reply to Re: MAOI diet » Larry Hoover, posted by cubbybear on September 28, 2004, at 11:56:46
> > A big part of my work is analytical chemistry, and modern equipment makes equipment from 20 years ago look like it came from the stone age, the changes are so dramatic.
>
> Is there any possibility that a person without your background can obtain and use equipment at home to test for tyramine in foods?!? Imagine how revolutionary that would be for MAOI users and doctors.To equip such a lab would cost in the six figures, I'm afraid. And learning how to use it is not something you could do in, say, a weekend.
Lar
Posted by Larry Hoover on September 28, 2004, at 12:43:48
In reply to Re: MAOI diet, posted by SLS on September 28, 2004, at 9:27:05
Posted by Ilene on September 28, 2004, at 13:17:47
In reply to Re: MAOI diet » Ilene, posted by Larry Hoover on September 28, 2004, at 8:07:26
> The only warning that I might add is more general. You don't know how the food you eat has been handled after it was produced. Safe foods can be contaminated by bacteria, and become unsafe. High protein foods are most likely to lead to tyramine contamination. That's why cheese, soy products, and meats are so prominent in the lists of foods of concern.
>
> Lar
>
>
I'm not too worried about handling. My understanding is that tyramine is a by-product of protein fermentation, which is why cheeses and meats that age for months are dangerous. High-protein foods that have been sitting around for a few days are not as likely to be a problem, except for the notorious chicken livers. We're also talking about fairly large amounts, e.g. grams or ounces, not a few crumbs.
This is the end of the thread.
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