Chasing Life

Welcome to Chasing Life, and the official first day of spring. You know, for many people, this means there are beautiful blooming flowers. There's warmer weather, great stuff. But for others, we know it can also be the dreaded start of allergy season. Here in Atlanta, it can get bad. In fact, they call it 'the pollening.' Now, if you're someone who has experienced a major or even minor allergic reaction to pollen or to foods, it can sometimes be irritating. But it can also be downright dangerous. It's happened to me, it's happened to my wife, I wanna share those stories today because frankly, they taught me a lot about allergies and I think they might be able to help you as well. Questions being, what exactly are allergies? Why do we have them? Why does our body do this? Are they the same as intolerance to things? And how do you know the difference? My guest today is Dr. Zachary Rubin. He's a pediatric allergist, clinical immunologist, and he just recently released his book called "All About Allergies." So today, we're chasing down the answers to allergies from pollen to peanuts, symptoms and myths. We're going to break it all down, connect the dots between the environment, between our exposures, and even our own genetics. I'm Dr. Sanjay Gupta, CNN's chief medical correspondent, and this is Chasing Life. First of all, I just want to welcome you to Chasing Life and just tell you that I'm a fan of yours. I have been following you on social media for some time. I've read your book, which I'm anxious to talk about. Yeah, congratulations. Today is the day.

Yes.

The book comes out. Let me ask you, if someone is listening and they say, look, I am someone who has allergies, concerned about allergies, at what point should they be seeing an allergist?

'Right, so there's several reasons. The first is if you have just seasonal allergies or hay fever and you've tried over-the-counter medications, they're not really working well. You need to get a formal test from an allergenist to figure out what is bothering you and then immunotherapy, which is actually a disease modifying treatment. We can train your immune system to become less reactive through a controlled exposure and so that can significantly improve somebody's quality of life and reduce their risk of developing new allergies if they're a young child, or even potentially developing asthma. It is something that we have been doing for about a hundred years now, and we know a lot about how it works, but all of the molecular mechanisms, we're still trying to figure out why this older therapy is so effective.

Why do people have allergies? Do they exist for some evolutionary reason? Are they protective in some way?

Yeah, we do think there is a bit of a protective nature to it. So as an example with food allergies, we know that that's been around for thousands of years, but just described differently, right? There's even ancient Chinese texts that talk about avoiding specific foods during pregnancy or different parts of life. So there's definitely evidence that it's been around and it's probably as a protective measure against toxins or parasites that were found in food and it became this more exaggerated response.

If people feel like their symptoms are bad enough that they need to see someone like Zachary Rubin, what would those symptoms be? At what point do you think, hey, look, this is bad enough that I need to go see a doctor?

'So from the seasonal allergy side, this is somebody who's having chronic sinus headaches, pain and pressure, terrible nasal congestion, they're not sleeping well, they've tried all the over-counter medications and they're getting quite relief from it. That's just the seasonal allergies side but we take care of a lot more than just allergies. You can see a dermatologist as well depending on what your availability is, but we would look at it from the standpoint of if you have severe eczema, what are the potential triggering factors for it, and now we have these biologic medications that have exploded over the past 10 to 20 years that actually will treat a very small portion of the immune system that's causing this abnormal response, leading to severe eczema or severe asthma. We take care of patients who have been on high doses of inhaled steroids and have had multiple asthma attacks, and we look at what are the triggering factors and how do we manage this appropriately. And we fill a niche throughout all these different specialties where we look the immune system and say, why is it abnormally responding to these foreign substances and how is this impacting people's lives where they're ending up in the ER, they're ended up in urgent care in the hospital, not exactly sure what's going on or the treatments given by their primary care physicians are just not quite enough.

Is the problem getting worse?

'It is unfortunately. So there are several factors for it and I discuss it in my book but one of the issues when we talk about chronic sinus infections or allergies is the fact that our global temperatures have been rising and that's correlated with the emissions of greenhouse gasses like carbon dioxide as an example. And we know that when you have higher CO2 in the atmosphere that causes pollen grains to be released more, earlier and stopping later in the season. So if you look at the general trends, our pollen counts have been steadily rising. So people are exposed to more of these allergens, therefore more people are developing allergies. If you look at all the allergic diseases put together, it's one of the top 10 most common chronic diseases in the United States are these different allergic diseases. Air pollution plays a role. The gut microbiome -- we're still trying to learn more about -- and its impact through early antibiotic use, early antacid use to treat reflux and babies. C-sections we know that the babies are exposed to the bacterial milieu and the birth canal. These are bacteria that help process whatever you're consuming and whatever you are exposed to. It's also on your skin. We have flora on our skin as well and so there's a lot of healthy bacteria but we often alter it through antibiotics or antacids, thereby presenting these different proteins to the immune system differently and that could increase the risk of developing these problems. So are there chemicals in the environment we're exposed to? So many questions that we're still trying to answer. We just don't quite have a handle on it yet.

So what can someone expect? They show up at an allergist's office. What are they likely to experience?

What usually happens is they'll get a bunch of paperwork ahead of time, just like with any other physician or specialist, that they fill out their general history before they come in. And then when I see them, I take a detailed history trying to figure out what are the specific symptoms that are bothering them, when are they bothering them? What are the potential triggers? What do they try to make it better or worse? And then we talk about allergy testing, whether that's going to be by blood testing your skin testing. I typically will do skin testing for most of my patients because we get an answer very quickly. We'll put the extracts of these allergens like pollen, dust, or mold on their skin, let that sit for about 15 minutes to see if they get what looks like mosquito bites. We call them wheels. They're like little mini hives. And that tells us that there's an indirect measurement of an antibody, a protein, called immunoglobulin E or IgE for short. That is something that your immune system makes in a process called sensitization, where it thinks it's basically a parasite, and that when you have subsequent exposure would lead to these allergy symptoms that people are experiencing. And so when we get that test result, we can then talk about ways to reduce exposure, what are the appropriate medications to take, and when you should take them, because I try to minimize the amount of medications they're using, and then we talk about immunotherapy as a potential option, so those allergy injections.

'How bad can this be? How life-altering can allergies be? We know that they can potentially be deadly. Someone might have an anaphylactic reaction, but just in life, how bad are we talking?

So it depends on which condition we're talking about, you know, if we talk about seasonal allergies as an example. Some people consider just a minor nuisance and you have severe symptoms where you're not breathing through your nose throughout the day and so you're that sleeping well at night. So I often talk about the nose being the gateway to your overall health And so when you have a situation where you have lot of inflammation your nose and mucus production, that increases your risk of having ear infections [and] sinus infections.

You spend a lot of time talking about allergies. You also spend a lot of time talking about misinformation online. Is there a lot of allergy misinformation?

There is actually in different ways, so I'll give a couple of examples. Food allergy is often the butt of a lot of jokes, it's not taken seriously online. And there's a story I think about that happened fairly recently, about a year or so ago, where a varsity high school football player in Texas had a peanut allergy that was very severe and he told his teammates they didn't take it seriously and they stuffed a bunch of peanuts in his clothes and in his locker. He ended up getting hives from it and he was being bullied because of it and nobody got in trouble at the school and his parents were very upset by it and they kept getting bullied. So he had to leave that school district, move to another school and, thankfully, there was a little bit of a redemption arc because his team that he went to won the state championship that year. To see so many kids bullied over their physical ailments when people don't really understand it well really bothers me and I am very passionate about it. You know, we see these jokes seem like it's not a big deal or it's funny to look at somebody having facial swelling or tongue swelling. And, I'm here to say that people living with food allergies should take this seriously, that your your story matters, that we need to help educate and advocate for folks living with these conditions because it's not a fad diet. It's not some type of choice, but I think the problem is that many communities have to provide accommodations that affect people who don't have food allergies and it's hard for them to understand how could something that you eat that sustains you could potentially end you, right? It doesn't really make sense, but this does happen affects close to ten percent of Americans and about half of the cases are in adults. And it's new to them.

Okay, how you doing? I know we're throwing a lot of information at you, a lot of big words, but we're gonna explain all this. Plus, exactly what point does something go from being a food intolerance, for example, to something being a true allergy? We'll be right back. My wife deals with pretty severe food allergies. And to be quite honest Zachary, in the beginning, I did not understand them. And with hay fever or seasonal allergies, I think maybe it's clear, maybe because people understand they get the sneezing, the sniffling, things like that. With food allergies, it seems like it can be more challenging. At what point does something actually become a food allergy, a diagnosable food allergy?

'Right. So a lot of people who think they have a food allergy don't and like you mentioned intolerance is very common. So what that means is is that you're having trouble digesting the food because you may not have the right enzymes in your gut to break down and so that can cause bloating abdominal pain and diarrhea. It's not life-threatening. It's not an immune system problem. It is a digestive problem versus an allergy to food It comes in different flavors actually, there's multiple subtypes. The one that's most common that people see is one where you eat a particular food, even in small quantities like peanut butter as an example, and it causes immediate symptoms. It could be as minor as itching or it could be hives, swelling, which the swelling can occur around your lips or tongue or throat to make it difficult to breathe. You could have repetitive coughing, wheezing, severe vomiting. You could have a combination of those symptoms I just mentioned or anaphylactic shock, which is when the blood pressure drops. And so there are also other kinds of food allergies that don't follow that pattern. And so you can have very severe, unusual symptoms that are related to food and it can interact with your body in different ways. And we've learned a lot about it, again, over the last 10 to 20 years, our knowledge has exploded on these issues.

You're a specialist, but for the average person or even the average doctor, can they easily distinguish these two things?

Usually you can when we talk about the severity of symptoms and what are they specifically doing, right? So what an intolerance is if you're eating something at a larger amount, you may start having symptoms. With an allergy, it's a very tiny amount. One bite could cause these symptoms. With an intolerance, it's much more than that. There's also another term that gets this confusing, though, which is that you hear a lot of people talk about sensitivities with foods. And the problem with that is it's an unscientific term. It's not validated. And so I can tell you the immune system's abnormal response when somebody's having an anaphylactic reaction. We can actually map that out on a board and talk about it. But a sensitivity is a nonspecific term where people will attribute, I eat this particular food and I will get headaches or nausea or joint pain or fatigue. And it's not to say that it's not real. The problem is is that I can't get a test to then verify that this is a sensitivity because we don't know the underlying pathway. I believe my patients. If they know that this particular food is causing them symptoms, even if it doesn't fit any pathway, I'll tell them, yeah, you probably shouldn't eat that and be careful. But I'm not going to prescribe an EpiPen for them, right? So we we often like to have tests to to validate our concerns, but I think doctors need to also validate people when they say, I know it's this, we need to look into it. And then even if we don't have the right answer, understand the risks and benefits of whatever intervention they wanna do and help them through that.

I'm curious about the sort of the commonalities between allergies and autoimmune diseases. What is happening in the body when someone has an allergic reaction?

Right, so there are definitely connections between the two and I'll get more into that in a second, but when we talk about an allergic reaction, it is actually a longer story than people think because you have to have an initial exposure to something. So let's say, I like using peanut butter as an example because it's a common one. You've been eating peanut butter your whole life and you're an adult. And one day, your immune system is shown peanut in a different way. Basically, your T and B cells as a part of your adaptive immune system are creating a different pathway called sensitization, where now your B cells are making these antibodies called IgE that are very specific, like a lock and key to that peanut protein. And then they'll sit on a cell of your immune system called a mast cell. That is the process of sensitization. You are now primed to potentially have an abnormal allergic reaction later on. So then later on, you have an exposure to it. Maybe you were exercising or you got sick and your body temperature is elevated. And you eat peanut butter and you didn't know it, but all of a sudden now your mast cells are activating, they're releasing histamine and other chemicals and it's causing this cascade of events that can lead to the symptoms we mentioned before. It could just be hives or it could be problems breathing or multiple symptoms. And it happens within minutes to maybe an hour. And so that's again, an abnormal immune system response to a foreign substance. That's what allergy is. Autoimmune disease is an abnormal immune system response to your own healthy tissue. And it's generally caused by, again, antibodies, these protein tags that your B cells make. Instead of latching onto a foreign substance, it may be to DNA fragments that are released from cells that have the normal cellular turnover because our cells don't live forever. So allergy, autoimmunity, oncology, cancer, all of it is connected and it's truly incredible. As we learn more about our immune system, we're gonna be able to unlock a better understanding of disease and how to manage and treat.

'I want to share something with you. And you just said something that I actually didn't realize. You said, if your body temperature is elevated, you may have a reaction that maybe you otherwise would not have had. When I was a resident in surgery -- you'll appreciate this. I'm an Indian family, we ate mangoes my whole life. It's just one of those things. We always had bowls of mangoes, especially in the summer. I went for a long run one day. I was at home, came home, bowl of mango sitting on the kitchen counter. And I had several pieces of mango, as I had been doing my entire life, and I was in my early 20s at this point. And it was the weirdest thing, Zach, I was sitting down on the chair watching television with my dad, and all of a sudden I couldn't see the bottom half of the screen. And I kind of like tilting my head like this to like, what's going on with my eyes? I thought this was an eye problem. I went into the bathroom and my face was swollen, including my lower eyelids, which were now obstructing my vision to some extent. And I had itchiness of the hands and all this sort of stuff. But again, the sequence of events, been eating mangoes my whole life, never had a problem. Went for a long run, now in my early 20s, eat that bowl of mangoes, and now I'm having a significant problem. That tracks based on what you were just saying, right? The run and the elevated body temperature maybe had something to do with it.

'Right. So there's actually a disorder called food dependent exercise induced anaphylaxis, where you eat mangoes all the time [and] no problem, but if you exercise intensely like right after eating it within an hour or two -- because you're still digesting it -- your immune system may all of a sudden start to react to it like never before. And so there are a lot of we call cofactors for severe anapholactic reactions. It's not just elevated body temperature, but illness as we mentioned earlier. It could also be taking non-steroidal anti-inflammatory drugs, NSAIDs like Motrin and ibuprofen or Advil or even Aleve. Those can modulate the immune response and make it worse. Alcohol does the same thing. So I always counsel all my patients with food allergies when they're about to go to college. You got to be careful if you're going to go to college parties because it could cause you to have a severe reaction if you are drinking and not thinking about what you're eating.

Does it go both ways? Can a food that I've had trouble with for a significant chunk of my life suddenly be presented in a way that's okay, that's favorable and not going to cause an allergy?

'Yeah, it depends on the type of food though that we're talking about. So if you developed a milk allergy as a young child, which I did actually, -- I had a milk allergy as a baby -- it can resolve. Most of the time it does. Egg allergy is now the most common food to be allergic to as a baby. It outpaced a peanut recently. And, that is one where in over half of babies, it'll go away, especially if they're able to tolerate it baked into things. And part of that is because certain foods have the ability that when you cook them, the protein breaks down enough that your immune system doesn't get confused anymore. It's a different protein, but there are certain similarities that when you regularly expose yourself, it'll train your immune to be less reactive and eventually it can resolve. But foods like peanuts, tree nuts, shellfish, they tend to be more persistent and less likely to go away.

What would be the guidance for someone who had the sort of story that I did? Fine most of their life, early 20s now, have a pretty significant reaction. I had to get epinephrine. By the way, I'll tell you really quickly, my mom ended up driving me to the hospital. I looked terrible, I was swollen, my hands were itching, the whole thing, and my mom, I never forget, she's like, you'll be fine, don't worry about it. You know, I will take you to the hospital if you want. We get to the the hospital and they recognize immediately and they give me a shot of epinephrine. It's kind of remarkable how quickly that works and how I felt better immediately. On the board, I guess, outside my room in the ER, it said respiratory distress. So all of a sudden the curtain flies open the attendings there and I'm, I'm fine at this point, Zach. I'm kind of, I think, I'm reading the newspaper or whatever. And he says to the resident, he goes, why isn't this man intubated?

What?

Yeah. And I was like, I'm okay. And this attending who was very reactionary, I think said, no, no, respiratory distress. Those patients go sideways in a hurry. You have to be on top of it. And at this point, I raise my hand as a resident in surgery and say, hey, just FYI. I think I'm okay. I'm breathing fine. I don't think I need to be intubated. And by the way, I'm a doctor, I am a surgeon. And my mom is sitting there and she goes, oh no, but he's just a resident. Do what you have to do. You gotta love her. And, so, I'm like, mom, they're going to put a tube down my throat. Should I no longer eat mangoes?

Well, so if you were to come into my clinic, what I would do is get some testing and see do you have those antibodies to mangoes? This happens sometimes. They'll have a reaction and then they eat it again and have no problem. And if we see that exercise is that trigger and we talk about that food dependent exercise induced anaphylaxis, I would say, okay, you're always going to have an EpiPen no matter what. And you should always have a buddy to exercise with just in case, right. You don't want to take that risk that's there's an accidental ingestion and you pass out. There's nobody there to give you epidephrine, right? But if you eat mango and wait about four to six hours, you probably are okay.

I do love my mangoes, so I want to eat them if I can. How do you think we do as a society in terms of requiring labeling of potential allergens in food? I read an article, maybe it was a couple of years ago, about sesame. I think sesame is now, there's required labeling around sesame. But it seems to me that there may be things out there that are problematic that have no requirement.

'Right. So there's a lot of issues in this area. You know, when you talk about the sesame label, I was a big proponent for, it was called the FASTER Act that was made into law, and it required sesame to put on the label so that if you have it, it has to contain sesame. Before, it might have said spices, it may have said 'may contains,' it wasn't really clear whether it was there or not. So what a lot of companies did that were making different food products where there might have been a little bit of cross-contamination there, but not to an effect that would have caused reactions for most people. One of the biggest challenges that we have right now is that the label 'may contains' or 'processed in a facility' or 'may contain trace amounts,' those are called precautionary labels that companies use to try to say, well, we think there might be something in there. We're not actively adding it. But when you're in a food processing facility with six different production lines, you don't know if peanut dust is going to spread to another production line. So we'll say it's made in the same facility. And from an allergist's perspective, it's really hard to counsel patients on whether that's safe or not.

That's interesting, that's counterintuitive for me, because I would have thought, you know, that just the precautionary principle would apply here. And so, for the vast majority of people, it would not be a problem, but you might have a small subset of people who would have a significant problem with that.

It's a real challenge because it creates unnecessary anxiety for a lot of people, but we're getting more data to suggest that if you have these labels that are precautionary, many folks can tolerate it. There was a study where they looked at about 200 kids with peanut allergies. They gave them a milligram of peanut protein and over 90% of them didn't have a reaction. And even if they did, there was no anaphylaxis. So we need to really work hard at risk calibration here. And a lot of what I do in my specialty is thinking about what is the risk of doing this, or that, or taking this medication, or reading this label. And this impacts people 24/7, especially if you have food allergies.

'There was a lot of news about peanut allergy specifically and the idea that maybe there was an over-tilt in terms of how moms, pregnant moms, babies should reduce exposure to peanuts. And now it seems to be tilting the other way. I'm just curious your take on this. Was it wrong? Was it an overreaction however many years ago to start limiting exposure to peanut so young and into pregnant moms? Or was that based on the best available evidence at the time?

So the way I think about it is that our understanding of science and medicine evolves. That's part of the scientific method. Our understanding of science and medicine evolves. So we weren't able to really get a good study at that time when the recommendations in the early 2000s were delay introduction of highly allergenic foods for those who were at high risk. And the problem was that high risk part of the recommendation I felt got lost in it where it became more of a general recommendation rather than saying, look, if you have severe eczema we do know that that's a higher risk of developing food allergies. And so that's not the only reason why we have more food allergies today because even if you look at the LEAP study where they randomized kids to say, all right, parents feed peanut protein before they turn one or wait until they're five. We know that the early introduction group was reduced by 80%. That doesn't completely tell the whole story, right? That's an 80% risk reduction. And we're just in peanut allergy. And we are now starting to see the benefits of that recommendation change about 12 years later, where peanut allergy rates are starting to go down.

So that wisdom now that we're hearing, that is what you would advocate as well.

'Yeah, early exposure. The only exception is if we already know somebody has an egg allergy or severe eczema, they need to talk with an allergist first to get formally evaluated to decide is it safe to introduce these or not. That's the current evidence-based guidelines.

My wife, and I'll just tell you quickly, she went through the gamut, Zachary. She was diagnosed with autoimmune diseases. She was diagnosed with psoriatic arthritis. She was put on drugs like Humira, for example. There was no good biomarker, meaning blood tests for her to take. It took years. She traveled around the country and was ultimately diagnosed with a Balsam of Peru food allergy. Something you've heard of?

Yeah, I have I mean there's these it's often referred to as systemic contact dermatitis where you know nickel is the more common one. I haven't personally seen balsam of Peru being the causative one, but I have seen nickel. Like there's nickel containing foods that can cause severe reactions for people, so you develop this contact allergy that becomes more systemic and and very problematic. So it takes a really good allergist, a good detective, to try to tease all of that out, and it takes time. And that's the one thing I always tell my patients and my followers on social media: Sometimes it takes a while to really figure it out because our testing is limited Our understanding is limited and we're learning a lot more now than ever before. But we don't know everything yet and we still have a long ways to go. So we we need to preach patience.

Shout out to Dr. Baker, who was that allergist you're describing, who is ultimately able to piece it together for her. I mean, it was bad. I would get home and she couldn't move. I would have to carry her up the stairs. And there was times when I'd say, what hurts? And she'd point to a specific place on her body and say, this is the only place that doesn't hurt. It was like every joint, her skin, everything. So, but doing a lot better, you know, and you know thankful to doctors like you for figuring that out. What is your advice for someone who who wants to lead a fulfilling life without constant worry or anxiety about allergies?

Yeah, so the first thing is really getting yourself educated about what food allergies is. What is the mechanisms behind it? how does it impact your life? What happens if a reaction happens? The knowledge portion, I think, decreases a lot of anxiety for people because it starts out you're told you have to change your life for something like this and it can really impact every aspect of it. It really does. But when you learn more about it, you're able to take that knowledge and apply it to everything. And now if people are developing anxiety from food allergies, there are actually specialized therapists who deal with this day in and day out to help families navigate situations. Oftentimes you only see the doctor once or twice a year, then you have somebody who can really help you navigate and have these coping strategies, which I think everybody can benefit from some form of therapy in their lives.

Zachary, Dr. Rubin, thank you very much for your time. I learned a lot, actually, and I think the audience will as well. Really appreciate it, and again, thank you for all you're doing, not only in writing this book, but just being a voice out there. I hope more people will tune into your social media platforms and buy the book. I read it, I loved it.

Thank you so much, it was really nice to meet you.

That was my conversation with Dr. Zachary Rubin. He's a pediatric allergist and author of the new book called "All About Allergies: Everything You Need to Know about Asthma, Food Allergies, Hay Fever, and More." Thanks so much for listening.