podcast Peter Attia 2023-10-30 topics

#277 ‒ Food allergies: causes, prevention, and treatment with immunotherapy | Kari Nadeau, M.D., Ph.D.

Audio

Show notes

Kari Nadeau is a physician scientist with expertise in treating food allergies. In this episode, Kari first explains the fascinating workings of the immune system, exploring how it adeptly defends against bacteria and viruses but how the same system can lead to food allergies. She proceeds to explore the complexities of food allergies, detailing their typical developmental patterns, underscoring the significance of preventative approaches like early exposure, and highlighting the potentially life-threatening nature of severe food allergies. Kari illuminates the latest advancements in immunotherapies that not only mitigate allergy severity but also hold the potential to completely cure the patient. Additionally, Kari shares her concerns about the increasing levels of air pollution, elucidating its adverse effects on health while providing valuable suggestions for reducing exposure.

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We discuss:

Kari’s motivation to study food allergies [4:00];
Overview of the immune system and the family of immunoglobulins [9:00];
How our immune system fights a virus, bacteria, or fungi, and some exceptions to the rule [13:00];
Why our immune system is generally better at fighting viruses than bacterial infections [18:45];
Differentiating a food sensitivity from a food allergy, and a discussion about celiac disease [25:30];
How food allergies develop, why they can be lethal, and factors contributing to the uptrend in food allergies [35:45];
The role of environmental factors in the onset of food allergies and strategies for prevention [50:15];
How immunotherapy helps to overcome, and even cure, food allergies [1:04:15];
Can immunotherapy work for environmental allergens like pollen? [1:24:00];
Air pollution: impact on health and tips for reducing your risk [1:25:30];
What happened to Kari’s early patient who died despite using an epinephrine device? [1:37:15];
Resources for those wanting to learn more or find clinical trials related to food allergies [1:40:45]; and
More.

Show Notes

Notes from intro :
Dr. Kari Nadeau is the chair of the Department of Environmental Health at Harvard School of Public Health, a professor of climate and population studies, and the interim director of The Center for Climate, Health, and the Global Environment
Kari’s research focus on the study of immunologic mechanisms involved in the causes, diagnoses, and therapy, for allergies and asthma
Kari earned her M.D. and Ph.D. from Harvard Medical School in 1995, completing her doctoral work in biochemistry and immunology
She’s a member of the National Academy of Medicine and has co-authored the book The End of Food Allergy: The First Program to Prevent and Reverse a 21st Century Epidemic
In this episode we talk about how the immune system works when it comes to fighting bacteria and viruses The same immune system that correctly helps us fight off bacteria and viruses incorrectly gets wound-up when it comes to food allergies You need to understand how the immune system works in the correct way in order to understand how it can go rogue
We deep dive into food allergies, and we distinguish them from food sensitivities
Many people listening to this will have some sort of food sensitivity (and that’s also potentially mediated by parts of the immune system), but what we focus on are true food allergies
Food allergies can range from mildly inconvenient to outright life threatening and debilitating It’s that latter area that we want to focus on
We talk about early exposure, we talk about immunotherapies that are available
If you have a peanut allergy and you don’t carry an Epi pen you can end up losing your life Peter wanted to understand why that’s happening He wants to understand what parents can do to reduce the risk of that developing in their kids And for those who already suffer from those things, he wants to understand: what are the immune-based therapies that can effectively make people who would otherwise suffer a lethal anaphylaxis reaction safe This is the kind of work Kari has been doing
We also talk a little about air pollution This was a real bonus for Peter because when he reached out to Kari initially, he thought they would only talk about food allergy Peter has a real interest in getting deeper down the rabbit hole of air pollution, specifically PM2.5 and we go into all of that in this episode
The same immune system that correctly helps us fight off bacteria and viruses incorrectly gets wound-up when it comes to food allergies
You need to understand how the immune system works in the correct way in order to understand how it can go rogue
It’s that latter area that we want to focus on
Peter wanted to understand why that’s happening
He wants to understand what parents can do to reduce the risk of that developing in their kids
And for those who already suffer from those things, he wants to understand: what are the immune-based therapies that can effectively make people who would otherwise suffer a lethal anaphylaxis reaction safe This is the kind of work Kari has been doing
This is the kind of work Kari has been doing
This was a real bonus for Peter because when he reached out to Kari initially, he thought they would only talk about food allergy
Peter has a real interest in getting deeper down the rabbit hole of air pollution, specifically PM2.5 and we go into all of that in this episode

Kari’s motivation to study food allergies [4:00]

It’s been 8 years since Peter and Kari were together in person
He always appreciated the amount of time she used to make for him when he would wander into her lab at Stanford, just to pick her brain
He always thought her work was exciting and knows that it ties into so much about what people are interested in around food allergies, even to some extent food sensitivities
It’s also very interesting to discuss air pollution This is probably something that isn’t getting enough attention with respect to health Peter feels woefully deficient in his understanding though he tries to pay attention to his PM2.5 but he’s not sure what to do with that information sometimes
Kari has now left Stanford and is at Harvard
This is probably something that isn’t getting enough attention with respect to health
Peter feels woefully deficient in his understanding though he tries to pay attention to his PM2.5 but he’s not sure what to do with that information sometimes

What Kari’s Ph.D. dissertation focused on

She was really excited to do her Ph.D. in biochemistry
She learned a lot about toxicology and biochemistry
She did her Ph.D. in parasitology working on an enzyme in a parasite called the trypanosome , which causes African sleeping sickness and another disease called Chagas disease

“ I loved my work there because we were able to go to the very minute levels of understanding of a chemical entity to be able to create a drug to target that entity to help people with that disease .”‒ Kari Nadeau

She did her Ph.D. at Harvard under Chris Walsh ; it was a great Ph.D., she loved it
Then she did other work in immunology and animal models
She is also a pediatrician by training

What led you to study the field of food allergies?

She did her M.D. training at Harvard and then trained in pediatrics at Children’s Boston as well as Stanford
With that, she had the opportunity to become a fellow in a feel that she loved: allergy, asthma, and immunology
She had done a lot of immunology work when she did her Ph.D. in parasites because parasites are killed by immune cells Especially this little molecule called IgE : it tends to kill parasites but it’s not so great for allergies
This yin and yang of this molecule [IgE] in biology as an immunologist was really interesting
Fast-forward, she was a fellow on the wards about to see a patient that she was being asked to consult on for a milk allergy He was in the ICU after having drunk a glass of milk and having a bad reaction By the time she arrived, he had died, and his parents were being asked to give consent for him to be a liver donor She took care of the person that received the liver who also had a milk allergy That gave her pause and really initiated her efforts in food allergy to understand the role of IgE (the role of the immune system) and how food allergies get started in the first place
Especially this little molecule called IgE : it tends to kill parasites but it’s not so great for allergies
He was in the ICU after having drunk a glass of milk and having a bad reaction
By the time she arrived, he had died, and his parents were being asked to give consent for him to be a liver donor
She took care of the person that received the liver who also had a milk allergy That gave her pause and really initiated her efforts in food allergy to understand the role of IgE (the role of the immune system) and how food allergies get started in the first place
That gave her pause and really initiated her efforts in food allergy to understand the role of IgE (the role of the immune system) and how food allergies get started in the first place

Kari wanted to know: “How in the world did a child with food allergy who died then give his same food allergy to the recipient of his liver?”

All of these things started to catalyze her curiosity, and she felt very blessed and lucky at the time to be able to be in a lab
She feels that we’re obligated to be able to use that training to best help mankind and to best help those questions that parents ask us
At the bedside of this particular young child that died, unfortunately due to a milk allergy, she’ll never forget his father trembling, asking why the EpiPen didn’t work? “ What can we do to help children in the future never have to die again? ” Kari promised that father that she would do the absolute best to prevent further deaths in children and adults with food allergy as well as help really make sure that we educate about the use of injectable epinephrine devices and how to best use them to prevent deaths to food allergy That’s her why, and ever since then she’s always wanted to really help out in this field
“ What can we do to help children in the future never have to die again? ”
Kari promised that father that she would do the absolute best to prevent further deaths in children and adults with food allergy as well as help really make sure that we educate about the use of injectable epinephrine devices and how to best use them to prevent deaths to food allergy
That’s her why, and ever since then she’s always wanted to really help out in this field

Overview of the immune system and the family of immunoglobulins [9:00]

You mentioned one of the immunoglobulins (IgE), talk about the family of immunoglobulins: what are they there for? How do we acquire them? How do they normally function?

We have certain proteins in our blood that help protect us and that’s what they’re meant to do and that’s great
And they exist in different concentrations Just like in a milkshake, you have different proteins that exist in different concentrations and they’re all there for nourishment purposes, sometimes for taste too
The proteins in our blood that constitute immunoglobulins are really helpful For example, we learned a lot about how important immunoglobulins were to protect against COVID Everyone wanted to know their “ titers ” and what that means is immunoglobulin
IgG is the main class of immunoglobulin, and those are very protective They are proteins found in high amounts in our plasma [the figure below summarizes the different classes of immunoglobulins, aka antibodies]
The minute someone is under a drug like a steroid (or other drugs that affect your immune system), the amount of immunoglobulin in the blood decreases
It’s important to have good concentrations (not too high), and immunoglobulins in general help protect us against infections and they also help protect us against allergies
There’s another complimentary suite of immunoglobulins that don’t just stay in our blood, they get into our organs Because you want to protect all of the surfaces around your organs (in addition to your blood) For example IgA class (we call that the secretory class) That’s helpful in our saliva, in our gut In women who are pregnant, they secrete it after pregnancy in their breast milk When people are missing IgA, they have allergies
Just like in a milkshake, you have different proteins that exist in different concentrations and they’re all there for nourishment purposes, sometimes for taste too
For example, we learned a lot about how important immunoglobulins were to protect against COVID Everyone wanted to know their “ titers ” and what that means is immunoglobulin
Everyone wanted to know their “ titers ” and what that means is immunoglobulin
They are proteins found in high amounts in our plasma
[the figure below summarizes the different classes of immunoglobulins, aka antibodies]
Because you want to protect all of the surfaces around your organs (in addition to your blood)
For example IgA class (we call that the secretory class) That’s helpful in our saliva, in our gut In women who are pregnant, they secrete it after pregnancy in their breast milk When people are missing IgA, they have allergies
That’s helpful in our saliva, in our gut
In women who are pregnant, they secrete it after pregnancy in their breast milk
When people are missing IgA, they have allergies

Figure 1. Classes of immunoglobulins (aka antibodies) . Image credit: OpenStax Microbiology

The other immunoglobulin class that Kari will talk about is IgM (the “Marines” of the immunoglobulins) IgM goes out on the first call They’re there to fight infections IgG comes in after IgM and they stay for much longer IgM doesn’t stay for very long
The final class is IgE In the past, IgE was very helpful for fighting parasites Now, unfortunately IgE still exists in our blood ‒ it represents 0.005% of all the immunoglobulins in our blood IgE has the lowest concentration of all immunoglobulins in the blood
IgM goes out on the first call
They’re there to fight infections
IgG comes in after IgM and they stay for much longer IgM doesn’t stay for very long
IgM doesn’t stay for very long
In the past, IgE was very helpful for fighting parasites
Now, unfortunately IgE still exists in our blood ‒ it represents 0.005% of all the immunoglobulins in our blood IgE has the lowest concentration of all immunoglobulins in the blood
IgE has the lowest concentration of all immunoglobulins in the blood

“ It [IgE] is unfortunately the most potent and I call it the match that lights the fire behind allergies ”‒ Kari Nadeau

You may think: why do we have such a skewed response? Why do we still have this prehistoric molecule floating around in our blood that truly all of us consider a bad actor?
We think it’s because of that prehistoric need to fight parasites, but importantly now fast-forward thousands and millions of years, it’s still there and it unfortunately has a skewed response in allergies
Why do we still have this prehistoric molecule floating around in our blood that truly all of us consider a bad actor?

How our immune system fights a virus, bacteria, or fungi, and some exceptions to the rule [13:00]

Explain cellular versus humoral immunity

Kari will explain how our immune system fights a virus or bacteria or fungi, but there’s always some exceptions to the rule
She’ll explain the general pathway to help people conceptualize what happens
She’s always amazed with the immune system, and there’s a lot we still don’t know
What we do know is that when something attacks us like a virus (or bacteria or fungi), that enters into our lungs (or gut or nose)
On the other side waiting for them is a whole panoply of immune cells ready to attack
If a virus gets in through the body Typically it doesn’t, we try to fight it right away But sometimes it does
Typically it doesn’t, we try to fight it right away
But sometimes it does

Let’s say a virus gets through our skin barrier…

Right away we have these cells called macrophages and they literally just eat up things So they bind on to the virus (or the bacteria or the fungi), and then eat it up into small little bits Then they expose those small little bits on their surface, and those small little bits on the surface, they actually then become the educator pieces for another group of cells called the T cell
T cells are what we call the cellular system
Macrophages are what we call antigen-presenting cells
These little bits [of virus (or bacteria/ fungi) that the macrophage chewed up] are called antigens
The T cell comes along and says, “ Huh, that’s interesting. I’m going to teach myself how to operate within these little androgens. What are these things? How do I train the immune system to get rid of this thing? ” The T cell will start to understand what this new organism is that just attacked the body and will fend against that
The T cell becomes what we call a memory cell
A memory T cell then teaches another cell called the B cell The T cell interacts with the B cell and trains it to make immunoglobulins for the exact little antigen [the T cell responded to], the antigen from the virus/ bacteria/ fungi
Then B cell then starts to make immunoglobulins
These immunoglobulins then bind to the antigen
And now you have specificity in your cellular and your humoral immune system
So they bind on to the virus (or the bacteria or the fungi), and then eat it up into small little bits
Then they expose those small little bits on their surface, and those small little bits on the surface, they actually then become the educator pieces for another group of cells called the T cell
The T cell will start to understand what this new organism is that just attacked the body and will fend against that
The T cell interacts with the B cell and trains it to make immunoglobulins for the exact little antigen [the T cell responded to], the antigen from the virus/ bacteria/ fungi

The humoral immune system refers to these antibodies that float in the blood

These antibodies [aka immunoglobulins] are not attached to a cell, but they were made by a cell [a B cell]
When these antibodies attach to the antigen, now a macrophage can recognize it There is this whole system we call antibody-dependent cell killing
Now that the antibody recognizes this virus as foreign, then these other cells (the macrophage) come back again and they chew the whole virus up and eliminate it from your body
There is this whole system we call antibody-dependent cell killing

That’s a long system—Kari just talked about things that take days to respond to, months to respond to

And it took many years of science to figure that whole pathway out
This is a lot of science and that science has allowed us to understand the immune system and provide vaccines to people
Because of this system our bodies know how to make immunoglobulins
Because of vaccines, we know how long they can last for
These memory T cells, for example, can last up to 100 years
The cellular humoral part of the immune system is very instructive to fight microbes
Unfortunately it doesn’t fight all microbes Some microbes need a little help with antibiotics, with antivirals So this story isn’t perfect, and that’s why you need to see the doctor You need to have other medicines for example to try to help your immune system fight infections Because there’s holes in the immune system and we need to help it
Some microbes need a little help with antibiotics, with antivirals
So this story isn’t perfect, and that’s why you need to see the doctor You need to have other medicines for example to try to help your immune system fight infections Because there’s holes in the immune system and we need to help it
You need to have other medicines for example to try to help your immune system fight infections
Because there’s holes in the immune system and we need to help it

Why our immune system is generally better at fighting viruses than bacterial infections [18:45]

Why do you think our immune system is, on balance, so much better at fighting viruses than bacteria, at least in terms of the clinically relevant ones?

Peter notes that very few people will take an antiviral drug in their life, outside of a handful of unusual circumstances
Most people will go through life with their immune system doing a very good job of lopping off the head of two to three viruses a year that actually reached the threshold of clinical significance
And yet most people don’t go more than two or three years without actually requiring an antibiotic to aid in the destruction of a bacteria
This is an excellent question teleologically as well as from an evolutionary point of view as well as really understanding how did viruses start in the first place? How did the bacteria start in the first place? What do they need to grow? From the perspective of the virus, why do they need us? From the perspective of bacteria, why do they need us? Same thing for fungi
When you think about a virus, they kind of flip from one organism to the other They sometimes can exist out in the wild, they don’t necessarily need us, but sometimes like HIV, it needs some of our cells to be able to live inside to be able to keep proliferating
There are some viruses that are of course very severe and they can cause fatal disease
Typically though, viruses aren’t as bad as bacteria
How did the bacteria start in the first place?
What do they need to grow?
From the perspective of the virus, why do they need us?
From the perspective of bacteria, why do they need us?
Same thing for fungi
They sometimes can exist out in the wild, they don’t necessarily need us, but sometimes like HIV, it needs some of our cells to be able to live inside to be able to keep proliferating

We don’t typically need an antiviral because we can fight viruses

It’s a great question though because viruses can mutate in our body like we saw with COVID and then all of a sudden we can’t fight them as well
But our body can much more easily to destroy a virus Because we make things like mucus, we have fevers We have these immune cells that are really programmed to attack quickly, and they can chew up the viral proteins much better
Because a virus is really relatively simple compared to a bacteria
So it doesn’t take a lot for the immune system to wipe that out because that virus is made out of simple things It’s basically made of really simple Lego blocks
But then you have the bacteria that’s made of an enormous amount of Lego blocks and it is much harder to destroy that
Same thing with fungi, they are much more complex organisms, they’re made of many different materials So that it’s harder for our immune system to kill every piece of the part and get rid of it
There are certain viruses though that we still get infected with but that they don’t cause fatalities They’ve learned to kind of use us and then move on because they want to just keep proliferating But they don’t necessarily stick around for our immune system to kill it They just keep being contagious
Viruses are much easier at hopping from one person to the other, whereas bacteria, that’s not so easy because they’re heavier, it’s harder to take a bacteria and give it to another human
With bacteria, we have this bimodal relationship: Kari wants to make sure all the viewers know that there are some bacteria that are actually really good We don’t know any viruses in particular that are actually good and beneficial for us But our body lives with bacteria
Because we make things like mucus, we have fevers
We have these immune cells that are really programmed to attack quickly, and they can chew up the viral proteins much better
It’s basically made of really simple Lego blocks
So that it’s harder for our immune system to kill every piece of the part and get rid of it
They’ve learned to kind of use us and then move on because they want to just keep proliferating
But they don’t necessarily stick around for our immune system to kill it
They just keep being contagious
Kari wants to make sure all the viewers know that there are some bacteria that are actually really good
We don’t know any viruses in particular that are actually good and beneficial for us
But our body lives with bacteria

Perhaps our immune system has a little tougher time knowing if this is a good bacteria or a bad bacteria

We’ve learned to be tolerant to certain bacteria but not others
Some of them escape our immune system if they are bad bacteria because they know that we have this tolerance to other bacteria that are in the same class
But it depends on where that bacteria is It’s totally fine if this bacteria is in your gut But the minute it gets into your blood, if it’s the same bacteria, it’s actually really dangerous That’s where our immune system has to figure out is this a bacteria in the gut? I’m okay with that Or is this bacteria in the blood? I’m not okay with that
And bacteria tend to divide so fast (just like viruses) and that makes it difficult
When we talk about vaccines , luckily we have used science to enable the immune system to get boosted for both types of infections (bacterial and viral)
It’s always hard to predict mutants, to predict different infections that one would have
It’s totally fine if this bacteria is in your gut
But the minute it gets into your blood, if it’s the same bacteria, it’s actually really dangerous
That’s where our immune system has to figure out is this a bacteria in the gut? I’m okay with that
Or is this bacteria in the blood? I’m not okay with that
I’m okay with that
I’m not okay with that

Peter’s analogy with cancer

What makes cancer so challenging for the immune system is that it’s basically self, and it’s very good at masking its non-self entities
So even though it’s genetically distinct from a non-cancer cell, it’s very good at hiding its neoantigens Sometimes they’re not even coding proteins In other words, sometimes the mutation in the cancer cell doesn’t lead to the generation of an antigen and therefore it can go completely undetected, masquerading itself
Kari adds that our memory T cells are supposed to be there to protect us, to monitor, and to make sure that any cancer cells are killed right away
Sometimes they’re faked out and that’s where CAR T cell therapy and a lot of the T cell mediated therapies (immune-mediated therapies) can enable and better instruct our immune system But that’s not perfect either
In COVID, we found that people that slept better, ate a healthy diet, and exercised, their immune system was healthier in general We learned a lot about what it takes to have a healthy immune system to better fight viruses and microbes
Peter adds, “ It’s hard to understate the harm that hypercortisolemia and a ramped-up sympathetic system have on the immune system .”
Sometimes they’re not even coding proteins
In other words, sometimes the mutation in the cancer cell doesn’t lead to the generation of an antigen and therefore it can go completely undetected, masquerading itself
But that’s not perfect either
We learned a lot about what it takes to have a healthy immune system to better fight viruses and microbes

Differentiating a food sensitivity from a food allergy, and a discussion about celiac disease [25:30]

Differentiate between a food sensitivity and an allergy

This comes up all the time with Kari’s patients, and she’s inspired by how much knowledge they have They come to the table with knowledge they received from the internet, podcasts, or just reading in general They ask questions ‒ this is so important
They come to the table with knowledge they received from the internet, podcasts, or just reading in general
They ask questions ‒ this is so important

If you don’t know something, feel free to ask your doctor these questions. This is critical.

Food sensitivity means that you can bite a food and you’re typically going to react to a chemical in that food, perhaps a protein But it’s mostly a small molecule, maybe a sugar, maybe a fat, maybe a spice And with that, people can get headaches, people can get bloating
A typical food sensitivity is lactose intolerance When you drink milk, for example, one of the sugars in the milk is called lactose And if you don’t have an enzyme in your gut and in your body called lactase, you can’t break down that sugar So that’s why people take lactate milk, for example There are some ethnicities that don’t have that enzyme, and they can’t drink cow’s milk because of that lactose sugar
With a food sensitivity, people get bloating, people get headaches, but they’re not going to have a fatal reaction
Peter clarifies, “ The immune system is not reacting at all in that state of a food sensitivity? ” Kari explains that it can react, but it reacts with a different pathway than an allergic pathway If you have enough lactose and you keep drinking lactose, your body can send some immune cells to try to break it down, and that causes inflammation
For some people, certain preservatives, emulsifiers, their immune system doesn’t like these chemicals They’re seen as foreign, and for some people, the immune system reacts But it reacts with a different pathway than an allergic pathway
But it’s mostly a small molecule, maybe a sugar, maybe a fat, maybe a spice
And with that, people can get headaches, people can get bloating
When you drink milk, for example, one of the sugars in the milk is called lactose
And if you don’t have an enzyme in your gut and in your body called lactase, you can’t break down that sugar
So that’s why people take lactate milk, for example
There are some ethnicities that don’t have that enzyme, and they can’t drink cow’s milk because of that lactose sugar
Kari explains that it can react, but it reacts with a different pathway than an allergic pathway
If you have enough lactose and you keep drinking lactose, your body can send some immune cells to try to break it down, and that causes inflammation
They’re seen as foreign, and for some people, the immune system reacts
But it reacts with a different pathway than an allergic pathway

A food sensitivity can cause bloating or headaches or even rashes… importantly, we don’t have cures or therapy for food sensitivities

If that’s happening to you, it is important to get tested because we want to make sure it’s not a food allergy
For food sensitivity, we often tell people to avoid that food
Kari knows someone who has terrible bloating with mushrooms because a certain chemical in them mushroom bothers her immune system The minute she even smells the mushroom, she gets an immediate reaction in her gut that causes her to vomit We don’t know why But it’s not a food allergy It’s an intense reaction of the nervous system to that food chemical
Sometimes Peter sees people who have a low-grade elevation of their C-reactive protein (CRP) (somewhere between 2-3, about 2-3x higher than it should be), and it lingers in this state for a very long period of time There’s clearly no infection In talking to them you realize it might be attributed to food
In Peter’s experience, the two foods that far and away account for the majority of this (as determined by simple elimination and watching this go away) are (1) wheat-related products and (2) dairy By wheat, he doesn’t mean celiac disease (which he’d like Kari to explain as a contrast but rather some sort of low grade sensitivity)
Peter asks for clarification about food sensitivities, “ There’s nothing going on in the IgE pathway, but there is something going on in the IgG pathway.” Again, C-reactive protein is made by the liver as basically a calling sign to the immune system For lack of a better word, you’re seeing the sirens going constantly, which is CRP
Kari agrees, CRP is a really good beacon to tell us that something is going on chronically in the immune system
When she tests CRP in patients with food sensitivities, and they’re not able to eliminate that specific chemical, then she sees CRP in that range where she calls it “ simmering immune inflammation ” It’s not a fire, but it’s simmering
The minute she even smells the mushroom, she gets an immediate reaction in her gut that causes her to vomit
We don’t know why
But it’s not a food allergy
It’s an intense reaction of the nervous system to that food chemical
There’s clearly no infection
In talking to them you realize it might be attributed to food
By wheat, he doesn’t mean celiac disease (which he’d like Kari to explain as a contrast but rather some sort of low grade sensitivity)
Again, C-reactive protein is made by the liver as basically a calling sign to the immune system
For lack of a better word, you’re seeing the sirens going constantly, which is CRP
It’s not a fire, but it’s simmering

“The problem with food sensitivities is I don’t have a great way to diagnose them. I don’t have a skin test. I don’t have an IgE test, I have to do elimination and then I follow that CRP level until it can try to get to zero.” ‒ Kari Nadeau

That’s not easy because some of these chemicals are so systematically in our food supply that it’s hard to get rid of
She also agrees that milk and wheat are some of the most associated culprits in food sensitivities in the US
That might be due to a lot of different reasons in terms of how we process How we have detergents in our milk The same thing with our wheat products It isn’t necessarily the same wheat that we ate when our ancestors ate it originally
How we have detergents in our milk
The same thing with our wheat products
It isn’t necessarily the same wheat that we ate when our ancestors ate it originally

More about wheat and this triangulation of food sensitivities/ celiac versus food allergy

Celiac is a very specific type of food sensitivity, and it has a very marched out pathway of immune reaction to wheat To wheat protein, specifically gliadin That reaction is to a very specific part of the protein of the wheat But not everyone with a food sensitivity to wheat has celiac And not everyone with celiac will have the same reaction to wheat as the food sensitivity people do
We take celiac extremely seriously because it can result in long-term problems with your gut It has its own special category
To wheat protein, specifically gliadin
That reaction is to a very specific part of the protein of the wheat
But not everyone with a food sensitivity to wheat has celiac
And not everyone with celiac will have the same reaction to wheat as the food sensitivity people do
It has its own special category

You shouldn’t call yourself celiac just because you have a food sensitivity to wheat; there’s a specific diagnosis that needs to occur with a professional that specializes in gastroenterology or in celiac

If you have celiac, then it’s important to test family members and to really get under the care of a good doctor

Are we seeing any increase in the prevalence of celiac disease or food sensitivities?

On one side, people are becoming more knowledgeable about this, and they also feel they have agency (as they should) when they come to the doctor to be able to say, “ I think I have a sensitivity of this food ” And people take them seriously and that’s good because these symptoms are serious, they’re affecting someone’s quality of life, and we need to help
In the past maybe they were poo-pooed and [doctor’s] said, “ Oh, I can’t help you, so I can’t do anything about that .”
But now, doctors can say, “ Let’s test that CRP. Let’s see if we can be better detectives and really try to help you ,” because in the end, we want to help quality of life
People are feeling more and more like they can talk about it as well as celiac disease, but importantly, we have better diagnostics As a community, we have gotten better at diagnosing celiac, and that’s another good reason why there might be more people with it
People also are seeing an increase in food sensitivities and celiac because of the different ways that wheat is processed Because of the different detergents now and unfortunate chemicals that are put into our foods Hopefully the food industry and agriculture will think carefully about those chemicals before they put them in
And people take them seriously and that’s good because these symptoms are serious, they’re affecting someone’s quality of life, and we need to help
As a community, we have gotten better at diagnosing celiac, and that’s another good reason why there might be more people with it
Because of the different detergents now and unfortunate chemicals that are put into our foods
Hopefully the food industry and agriculture will think carefully about those chemicals before they put them in

When Kari tells people not to eat foods with those chemicals in them, they tend to not have food sensitivities

How food allergies develop, why they can be lethal, and factors contributing to the uptrend in food allergies [35:45]

Do you have a sense of how many people in the United States die in a year as a result of a food allergy like the tragic story you told?

Thankfully, that’s extremely rare
Kari hedges this a bit because sometimes it’s a little blurry if someone died from a food allergy, with the codes in the emergency rooms/ intensive care units
Epidemiologists say it’s very rare (Kari is not an epidemiologist)
People have claimed one of the reasons why people can have a fatal attack is because they don’t have access to an Epi device or they don’t have anticipatory guidance for what to do during a reaction

“ Any fatal reaction could have be avoided ”‒ Kari Nadeau

Kari hears about approximately 1 fatal reaction per month in the US

Every one of those stories comes with a tragedy that’s heart-wrenching
It compels Kari to keep training her patients To make sure they have two injectable epinephrine devices at all times To make sure they know how to use it within a minute To make sure that if it doesn’t help their symptoms within a minute that they use another right away To know it’s okay to use an injectable epinephrine device because that’s the only thing that can actually prevent the unfortunate death
The numbers right of death rates are getting lower, which is good, because people are understanding more about this disease and communities understand why we don’t want to expose people unnecessarily to foods that could kill them
There are increasing incidents and prevalence of food allergies in general in the U.S
To make sure they have two injectable epinephrine devices at all times
To make sure they know how to use it within a minute
To make sure that if it doesn’t help their symptoms within a minute that they use another right away
To know it’s okay to use an injectable epinephrine device because that’s the only thing that can actually prevent the unfortunate death

Ruchi Gupta out of Chicago, published data that 1 in every 12 children in the classroom in the U.S. has a doctor’s diagnosis of food allergy

[figures from this study are shown below]

Figure 2. Percent of children in the US with food allergies (FA) . Image credit: Pediatrics 2018

Figure 3. Symptoms of an allergic reaction with stringent symptoms indicative of a convincing food allergy highlighted . Image credit: Pediatrics 2018

When Kari was training, it was thought that children would lose their food allergy Especially those with milk and egg If they were under the age of five, there was an 80% chance that they would lose these allergies by the time they were teenagers But if it was peanut or any kind of tree nut or shrimp or fish, they had an 80% chance of keeping it
Now unfortunately, if you have a milk or an egg allergy and you’re under the age of five, you have a 50% chance of losing it
So now we see more and more adults having food allergies
The other unfortunate thing is that more adults when they get to adulthood are getting food allergies
Especially those with milk and egg
If they were under the age of five, there was an 80% chance that they would lose these allergies by the time they were teenagers
But if it was peanut or any kind of tree nut or shrimp or fish, they had an 80% chance of keeping it

Presumably about 1 in 30 adults will have some type of food allergy when they’re an adult

Whether or not that’s because they had it when they were children or because they gain it newly when they’re an adult

The numbers of food allergies are rising, but luckily the death numbers are not (someone needs to do more research on that)

This compels Kari as a food allergist to really make sure that both children and adults understand this disease and how to manage it
The rising incidence and prevalence of food allergies is occurring throughout the world It’s not just a problem in the US
It’s not just a problem in the US

How a food allergy occurs

Peanut allergies are a problem in the US, the UK, and Australia But not in Italy ‒ where allergies to hazelnuts are #1
In Japan, it’s allergies to fish
In China, it’s allergies to milk
But not in Italy ‒ where allergies to hazelnuts are #1

A peanut allergy is an example of how our immune system reacts to something, and a very similar immune reaction occurs in other types of food allergies

Kari has seen a spectrum of allergies Allergies to cinnamon Allergies to orange pit seeds
Allergies to cinnamon
Allergies to orange pit seeds

All of these have proteins in them so people can actually become allergic to these proteins

People can have allergies to the tannin proteins from grapes in wine

“ I’ll tell about the story of the peanut, but I want people to know that it’s not just about peanuts, and many people that have allergies to one food have allergies to other foods. ”‒ Kari Nadeau

If you have a child with a food allergy, it is highly likely they will develop another food allergy as well

It is important to be super careful and vigilant about taking your child (or yourself) to the doctor to manage food allergies and get diagnosed
When a person starts to have a food allergy, about 70-80% of the time it’s NOT genetic but environmentally related

How a food allergy begins

When a baby is born, perhaps their skin is a little rough and a little dry and there might be microscopic holes in that skin That happens a lot now a lot of children have dry skin With that little dry skin, the epithelial cells that are typically connected and form a nice beautiful barrier, they separate, and our body doesn’t know how to deal with this separation too well It thinks it’s a mosquito bite, and it’s like, “ Wait, what the heck is happening? I have a little hole in there. ” It reacts to these types of holes as if it was a mosquito bite And all of a sudden in the air you have dust that might contain hazelnut protein or in this case, peanut protein, and that comes settling in and it goes through this hole [in the skin]
Our body has a very prehistoric way of dealing with this, which gets back to parasites
Allergens come in by passive aeration, it drops down on the skin
The body tries to pick it up, and the immune system tries to sense, “ What the heck is this? Is this good or bad? ”
Then it says, “ Wait, this is bad. I’m not supposed to have food through my skin. I’m supposed to have food through my gut .”
So the cell [the macrophage ] takes it up and activates the allergic pathway because it thinks it’s a parasite, it thinks it’s a mosquito bite
[The macrophage] takes up the food, processes it, teaches a T cell to interact with that food antigen and then a B cell starts to make IgE against that very same food antigen
Now, the next time that baby eats a peanut, even if it eats it through the gut, that little IgE molecule will have been made by the B cell and it’s sitting around in the blood IgE will bind to the peanut protein that the baby eats Remember, the IgE is a very small percentage of the concentration of proteins in the blood, but it is a potent molecule It’s what Kari calls, “ The match that lights the fire behind allergies ”
In a person with an allergic reaction to peanut, that IgE binds to the peanut [circled in the figure below] and then this part of the IgE molecule [the Fc portion, at the bottom of the molecule] is recognized by a receptor on another cell
That happens a lot now a lot of children have dry skin
With that little dry skin, the epithelial cells that are typically connected and form a nice beautiful barrier, they separate, and our body doesn’t know how to deal with this separation too well It thinks it’s a mosquito bite, and it’s like, “ Wait, what the heck is happening? I have a little hole in there. ” It reacts to these types of holes as if it was a mosquito bite
And all of a sudden in the air you have dust that might contain hazelnut protein or in this case, peanut protein, and that comes settling in and it goes through this hole [in the skin]
It thinks it’s a mosquito bite, and it’s like, “ Wait, what the heck is happening? I have a little hole in there. ”
It reacts to these types of holes as if it was a mosquito bite
IgE will bind to the peanut protein that the baby eats
Remember, the IgE is a very small percentage of the concentration of proteins in the blood, but it is a potent molecule It’s what Kari calls, “ The match that lights the fire behind allergies ”
It’s what Kari calls, “ The match that lights the fire behind allergies ”

Figure 4. Structure of an antibody with the antigen-binding site circled and the Fc region at the bottom . Image credit: Wikipedia

The IgE bound to the peanut allergen now docks via the antibody’s Fc region into a receptor on a cell and activates histamine release by that cell [shown in the figure below] That occurs within minutes
That occurs within minutes

Figure 5. IgE-mediated allergic response . Image credit: The Biologist

Within 6 minutes, histamine goes through the body and causes swelling and mucus release (in your lungs, eyes, or nose), itching on your skin The itching is very similar to what would happen if you got a mosquito bite In the same way that your body wants to get rid of that mosquito, it wants to get rid of that food
The body’s trying to do something that it was meant to do prehistorically, but it doesn’t help the person at all
Histamine levels become so high that it can sometimes cause death Within minutes if you already have asthma or lung issues That mucus can become so strong that it clogs up your lungs
What often can lead to those rare fatal reactions is there’s another chemical released by these cells when the IgE docks into the receptor, called bradykinin
Bradykinin can affect our blood pressure system That can lead to dizziness and heart issues That’s the second reason why people have fatal reactions
You can imagine when you take epinephrine through an injectable epinephrine device, that helps both the lung to clear the mucus, and it helps the heart and the blood pressure stay strong so that you don’t have one of these near-fatal or fatal reactions But it all is linked to the immune system and how it reacts, and it’s a very fast reaction
The itching is very similar to what would happen if you got a mosquito bite
In the same way that your body wants to get rid of that mosquito, it wants to get rid of that food
Within minutes if you already have asthma or lung issues That mucus can become so strong that it clogs up your lungs
That mucus can become so strong that it clogs up your lungs
That can lead to dizziness and heart issues
That’s the second reason why people have fatal reactions
But it all is linked to the immune system and how it reacts, and it’s a very fast reaction

Is my memory correct that the cell that’s releasing the histamine a mast cell ?

You’re seeing both sides of the story for the immune system
The humoral response , which is IgE
And the cellular response ‒ mast cells, eosinophils, and basophils all have a receptor on them to bind an IgE (shown in the previous figure) There’s another type of disorder called eosinophilic disorders, which is a different type of food allergy but also related Mast cells exist in tissues, but they’re not in the blood Eosinophils and basophils are in the blood
This is a potent system because it’s got these cells ready to go in the tissues,
Mast cells are in the skin, they’re in the gut, they’re in the lung, in the eyes, in the nose Mast cells can live a very long time in tissues, and that’s why someone’s reactions can build up over time, because every time they eat that food (or have that allergen exposure), their mast cells are going to remember because of the immunoglobulins that bind to them
These other cells are floating around the blood and are also secreting histamine and bradykinin They’re like the messengers across the whole system
There’s another type of disorder called eosinophilic disorders, which is a different type of food allergy but also related
Mast cells exist in tissues, but they’re not in the blood
Eosinophils and basophils are in the blood
Mast cells can live a very long time in tissues, and that’s why someone’s reactions can build up over time, because every time they eat that food (or have that allergen exposure), their mast cells are going to remember because of the immunoglobulins that bind to them
They’re like the messengers across the whole system

The implication is that each successive exposure gets worse

How often is a person’s first brush with a food allergy a fatal one?

We’re only as good as our data, as our epidemiological studies
There are always exceptions, but typically, if you learn about your allergies before the age of two, those food allergic reactions are typically vomiting and hives They’re not typically related to lung and heart
Typically babies and toddlers do not have fatal reactions to their first ingestion of food Although there are rare exceptions
They’re not typically related to lung and heart
Although there are rare exceptions

If you dissect out who dies from a food allergy, it’s typically people that already have a heart problem, already have a lung problem or didn’t get to the EpiPen fast enough

It would seem logical that with every dose that you take, your reaction could get worse and worse with the same dose, but it depends on: If your at elevation If you already have a cold If you have aero-allergies and you’re allergic to a dog and a dog came by you that week and you also ate a peanut
But yes, in general, if all things being equal each time you ate it, your immune system would remember more and more and will boost up that response
If your at elevation
If you already have a cold
If you have aero-allergies and you’re allergic to a dog and a dog came by you that week and you also ate a peanut

Luckily with therapy, there’s a way to retrain your immune system, but that takes regular interaction with the food every day, not every week

If you take it every week , it actually boosts your immune system to become more allergic
If you ou take it every day , there’s something to the circadian rhythm and the diurnal cycle, (which we haven’t talked about yet) You can train it away from becoming allergic and train it into becoming more protective
You can train it away from becoming allergic and train it into becoming more protective

“ What I love about the immune system is it can be trained, and you just need to know how to train it .”‒ Kari Nadeau

The role of environmental factors in the onset of food allergies and strategies for prevention [50:15]

What are other environmental factors that predispose children and adults to food allergies?

Earlier Kari mentioned dry skin
The lack of certain factors also predisposes people
People have talked about having a good microbiome and how “good dirt” helps decrease the likelihood of food allergies For example, children who grow up on farms and have good exposure to animals tend to not have as many food allergies This is called the “dirt hypothesis” Also growing up with animals like dogs helps reduce the likelihood of food allergy, and that’s probably due to the microbiome
Vitamin D also seems to play a role ‒ having enough vitamin D decreases the risk of food allergies
Being around too much detergent is a risk, this is what Kari calls the “dry skin hypothesis” Detergents for washing clothes and our dishwashers are really potent, and it’s not getting rinsed away enough A babies skin (though it heals so well) is somewhat more sensitive than adult skin
Babies tend to have dry skin do to other issues let alone detergents
Anytime in life, pollution or tobacco smoke causes dry skin and itchiness
Any part of the body that touches the air can be affected: our lungs, our gut
For example, children who grow up on farms and have good exposure to animals tend to not have as many food allergies
This is called the “dirt hypothesis”
Also growing up with animals like dogs helps reduce the likelihood of food allergy, and that’s probably due to the microbiome
Detergents for washing clothes and our dishwashers are really potent, and it’s not getting rinsed away enough
A babies skin (though it heals so well) is somewhat more sensitive than adult skin

One hypothesis is that allergies begin through the skin

We also think that it’s really important to diversify your overall diet really early and often

Feed certain proteins to your children when they’re young, and that diversity in diet can prevent the advent of food allergies later on in life

The 5 D’s to preventing food allergies : dirt, dogs, detergents, vitamin D, and diversity in diet

Dry skin does seem to be a conduit by which food allergies start
People will say that their parents gave them this food allergy or it’s in their genes

There are certain allergies that can be passed on from one generation to the next, but even with those diseases, if you change your behavior, that can decrease the likelihood of having food allergies

Kari’s advice

Improve your skin barrier
Try to stay away from emollients that are petroleum-based or paraffin-based products (like Vaseline)
Science has shown us these are not natural to the skin
Our skin doesn’t really like wax or petroleum products

Vaseline is a petroleum product that tends to increase the bacteria on our skin, and that can make skin inflammation worse

Try to choose products that have natural lipids that give the skin back what they’re missing

How does one look for that on the label?

Ceramide is a natural lipid, and you want to look for those emollients that actually replete the skin with natural lipids
CeraVe is a brand that has ceramide in their products
Kari doesn’t work for any of these companies
Choose ecologically-friendly detergents because those tend to be better for our own bodies
Also try to rinse things

Is there any relationship with breastfeeding?

Do we see any difference in the incidence of food allergies in a child who’s breastfed or not breastfed?

Many of Kari’s colleagues in Europe have tested this
Now breastfeeding is so much that standard that it’s hard to do these studies
The World Health Organization has recommended breastfeeding
It’s really important to start feeding infants other types of foods between 4-6 months of age
In general, breastfed infants do do better in terms of their overall gut health, in terms of their overall health in general

But it has not been shown definitively that by breastfeeding you can prevent food allergies

Breastfeeding is very helpful towards creating an overall healthy immune system
Kari tells all her families, “ If you can breastfeed, please do .”
But the ulterior, unfortunately, is that some children can have an allergy to a protein in the mom’s breast milk (it’s very, very rare) So if your child does start to have issues with your breastfeeding, go see a doctor and make sure that they don’t have an allergy to your own milk
So if your child does start to have issues with your breastfeeding, go see a doctor and make sure that they don’t have an allergy to your own milk

What is the case for and against early exposure to nuts as a vehicle to prevent the onset of one of these allergies?

This has been confusing, and there’s been a lot of flip-flopping
Unfortunately, well-meaning people made guidelines 20 years ago that weren’t based on a lot of data They saw the increase in food allergies throughout the world and reacted, “ Oh, we don’t have enough science, but we’re really worried. So let’s just tell people to avoid those foods. And hopefully that can prevent this epidemic from increasing. ” And the minute those guidelines came forward, you started seeing a hockey stick in the epidemic (food allergies started to increase) While in those countries that did not follow these guidelines, it stayed flat
Peter reacts, “ That’s a very telling case, even though it’s not a randomized intervention, that says when you avoid foods at a young age, you paradoxically predispose to the allergy. ”
They saw the increase in food allergies throughout the world and reacted, “ Oh, we don’t have enough science, but we’re really worried. So let’s just tell people to avoid those foods. And hopefully that can prevent this epidemic from increasing. ”
And the minute those guidelines came forward, you started seeing a hockey stick in the epidemic (food allergies started to increase)
While in those countries that did not follow these guidelines, it stayed flat

The importance of guidelines

We’re only as good as our data
Fast-forward 20 years and now the world has different data We now think that allergies begin through the skin, and through the diet allergies can stay quiet We now know that the gut is really important for tolerizing to those antigens.
We now think that allergies begin through the skin, and through the diet allergies can stay quiet
We now know that the gut is really important for tolerizing to those antigens.

“ The immune system in the gut is meant to tolerize. The immune system in the skin, in our lungs and in our skin is actually meant to be activated and react .”‒ Kari Nadeau

When you think about that dry skin hypothesis, of course it’s going to promote allergic pathways
But when you think about taking things through the gut, it’s going to promote tolerogenic pathways
The same people who wrote the guidelines 20 years ago, came together again to say, “ We need to diversify the diet. We need to tell our country’s population to start having children eat foods in small amounts like tree nuts, like fish, like milk, like egg, like peanut, and to be able to have that early and often and regularly so that we can try to prevent food allergies. ” That’s the general mantra The guidelines have now switched
The same thing for people who are pregnant It used to be thought based on a very small study of only 20 individuals, that women who are pregnant should avoid peanuts and tree nuts 20 years later after a much bigger study was done, it showed it’s definitely okay to have peanuts and tree nuts when you’re pregnant It’s healthier with omega-3’s
Of course, people who already have food allergies shouldn’t be eating these foods when you’re pregnant or if you’re a child
That’s the general mantra
The guidelines have now switched
It used to be thought based on a very small study of only 20 individuals, that women who are pregnant should avoid peanuts and tree nuts
20 years later after a much bigger study was done, it showed it’s definitely okay to have peanuts and tree nuts when you’re pregnant It’s healthier with omega-3’s
It’s healthier with omega-3’s

Regular exposure to foods helps prevent the development of food allergies

But it does seem to be important, and it goes back to those instrumental recipes of the immune system
If the immune system can probe the antigen, know that it’s safe, know that it’s not going to harm the immune system or the body, it then becomes tolerant
But in order to give it that instruction sheet, you need to feed and you need to get exposed regularly

“Regularly” means every day to every-other-day

You may say, “ My grandmother didn’t have to feed me these foods regularly. What all of a sudden changed? ”

We think the environment around us is changing

The environment is changing with different detergents, different emulsifiers, different chemicals in our food, different pollutants, different viruses

Do you think the genie ever gets back in the bottle? Do we ever get back to the levels we had 30 years ago?

When Peter was a kid, he did not know another child that had a food allergy All the way through grade school, middle school, high school
Today, his kids can’t take nuts to school
You can’t have nuts on an airplane today
Peter can’t tell how much of this is overreaction
There’s clearly a log-fold change, but he can’t tell how much of this is also just a “disease of the brain”
Lots of epidemiologists have asked this question and tested it, and it’s real
There were people who rarely had a milk allergy or peanut allergy, and the allergist focused on aero-allergens
Now their offices have shifted to food allergy
All the way through grade school, middle school, high school

This is a real diagnosed food allergy, and Kari doesn’t think we’re ever going to get back to 30 years prior because we had different practices, different ways of processing food, different environmental exposures

“ This is mostly environment, if I have identical twins born to the same mom and dad, I can have one twin develop a food allergy and the other one doesn’t (and typically, that’s in adulthood). ”‒ Kari Nadeau

The one twin that develops a food allergy, they’re the one who’s been out in pollution more, they’ve eaten not such a healthy diet, they have a lot of preservatives Or they smoke or they eat a lot of fast food Or they are under a lot of stress and they don’t get a lot of sleep
Or they smoke or they eat a lot of fast food
Or they are under a lot of stress and they don’t get a lot of sleep

So genetics being equal, exposures in early life being equal, there are certain behaviors that we’re seeing that are more associated with food allergy (like air pollution)

Luckily, science has helped us so that we know what to do now and how to change our behavior so that we can try to prevent food allergies from worsening

How immunotherapy helps to overcome, and even cure, food allergies [1:04:15]

Peter met Kari about a decade ago through a mutual patient who at the time was being treated by her
Peter was blown away at the fact that a person who once had an anaphylactic reaction to nuts was going through an immunotherapy-based sensitization program with Kari at Stanford, and then all of a sudden didn’t have an anaphylactic reaction to nuts

Give us a sense of what this revolution in immunotherapy-based sensitization is about?

Peter adds, “ It’s sort of hard to wrap our head around when you consider the lethality of these conditions”
Kari’s colleague, Kim Yates has don a lot of work in this area to educate
Organizations like FARE and others have really moved the needle forward
When you think about food allergies, it’s something a child (or an adult) has to live with, and it’s not fun It can affect their social lives or quality of life
So they often come to the table wanting to know what is the best therapy now
We now have a lot more therapeutic options Any of these decisions are really personal They’re something that the doctor, the healthcare provider, should talk to the patient about and see what’s the best for them
It can affect their social lives or quality of life
Any of these decisions are really personal
They’re something that the doctor, the healthcare provider, should talk to the patient about and see what’s the best for them

Getting back to the immune system, regular eating of foods will retrain the immune system to be tolerant to those foods, to see them as natural (not unnatural)

This has been going on for about 100 years, even though it is new to many of us Work Kari did at Stanford built upon evidence and other clinical trials Kari worked closely with the FDA because you don’t want to do anything that’s not safe, anything you wouldn’t want to do with your own children
Work Kari did at Stanford built upon evidence and other clinical trials
Kari worked closely with the FDA because you don’t want to do anything that’s not safe, anything you wouldn’t want to do with your own children

What you do in immunotherapy at the very basic level is give the person back the very same thing that they’re allergic to

This was done 100 years ago with dog allergies, cat allergies, grass allergies, mold allergies
People would start to inject these things
A lot of patients may have had allergy shots when they were little
These are ways immunologists learned to retrain the immune system
You can train a body so that they are no longer allergic to cats, for example
But you need to keep taking those allergy shots in general
The same thing is true for food, but you don’t want to give a food allergy shot because the food in and of itself is very potent

Food allergies are an IgE-mediated disease, and injecting allergic foods can be extremely dangerous, so we don’t give it via injections

Peter asks…
“ Just to be clear, the allergy example, let’s say it’s cat dander or whatever, is the shot giving you a little bit of that dander? Is it sensitizing to you a little bit? ”
A nd how frequently does the patient need allergy shots to achieve a symptom-free existence ?
Initially, you need to take it almost daily, daily to weekly
Once your body starts to build up that immune muscle, you only need to take it about once a month
Some people do it for life, and some people do it for 5 years

For an aeroallergen (not a food allergen)

If you stop after 5 years, you have a 25% chance of regaining your allergy, a 25% chance of having the allergy to a lesser degree, and a 50% chance of having the allergy be resolved for the rest of your life These are for environmental allergies, and 5 years depends on the aeroallergen
The reason you can get away with that is because these allergens do not induce anaphylaxis the way food does
It’s the severity of the IgE mast cell reaction to food allergens that is different, and we’re still trying to understand why that is E.g., Why is grass allergy not as bad as peanut allergy ?
These are for environmental allergies, and 5 years depends on the aeroallergen
E.g., Why is grass allergy not as bad as peanut allergy ?

Immunotherapy is giving small amounts of that specific allergen back to the patient, and this can be a shot for environmental allergies or orally for a food allergy

For a food allergy

You start with a small spec that you can hardly see and then you increase that dose by 25% every 2 weeks, but you’re giving it every day
You increase it step-by-step: every 2 weeks you increase the dose, but you’re giving it daily
And you want to do that in a doctor’s office, you want to be really careful about that
Over time, this readjusts the immune system, but it takes a while

What happens in the immune system

What happens in the immune system is the T cells start to be taught that this antigen seems to be okay
When they get it every day they realize, “ I need to reframe my mindset. ”

You start creating another whole layer of memory T cells that become tolerant to that antigen

The new memory T cells teach the B cell to forget making that IgE Instead, they want the B cell to make more IgG because that’s protective
This happens over time during the first year of immunotherapy You’re slowly going up, slowly readjusting
Instead, they want the B cell to make more IgG because that’s protective
You’re slowly going up, slowly readjusting

The patient’s immune muscle switches from an IgE-mediated bad reaction to an IgG reaction that is protective against the allergy

The IgE can still be there but you have this huge amount of IgG that is protective The IgG acts like a blanket of immunoglobulins that covers the allergen so that none of the allergen binds to the IgE [Illustrated in the figure below]
The IgG acts like a blanket of immunoglobulins that covers the allergen so that none of the allergen binds to the IgE
[Illustrated in the figure below]

Figure 6. Tolerance to food antigens is mediated through IgG immunoglobulins . Image Credit: Frontiers in Allergy 2021

In the case of the person with the anaphylactic reaction to peanuts, do they ever go above the 0.005% IgE concentration [in the blood]?

In order to have that reaction, IgE is specific to a specific food
People with peanut allergies (or other allergies) will have a higher concentration of IgE
A virus can also increase IgE non-specifically (probably against the virus)
It’s a very prehistoric type of reaction
But importantly, for every IgE molecule, we can make 100 IgG molecules that protect against that IgE molecule circulating and becoming potent, and that’s what is happening during immunotherapy [shown in the previous figure] You’re making huge amounts of IgG molecules to bind against that IgE becoming pathological It’s a ratio thing
You’re making huge amounts of IgG molecules to bind against that IgE becoming pathological
It’s a ratio thing

Give me a sense of scale. So on the very first cycle, that first two-week cycle, what fraction of a peanut is being given in the capsule? How small is it?

It’s about 1/200th of a peanut
You start very low and you go very slow, because in the end you want to retrain that immune system, but you don’t want to activate it too much
Now, during that retraining, sometimes your “muscles” get sore Sometimes you will see some hives, sometimes you will get a little itchy throat Your body will have these little reactions, Kari calls them simmering reactions
But you do need to take it every day
And then you start to see this switch from IgE to IgG The T cells are responsible for that; many other cells are too
But in general, if you stop the therapy, this beautiful pathway of tolerance then starts to go back to the original pathway
So it’s really protection and it’s very rare that a person completely flips and becomes non-allergic
Sometimes you will see some hives, sometimes you will get a little itchy throat
Your body will have these little reactions, Kari calls them simmering reactions
The T cells are responsible for that; many other cells are too

What you’re doing in the immunotherapy is changing your threshold and creating more protection molecules around you and creating more protective cells around you

When does that switch flip?

In a typical immunotherapy regimen, it flips around 9 months to 1 year
Peter thinks about the doses they’re talking about, “ Someone comes in with an allergic reaction to peanuts, for two weeks they’re going to take a capsule that contains one 200th of a peanut. That goes according to plan, they will increase that by 25% for another couple of weeks. A month into this thing, they’re still basically taking one 200th of a peanut, but you will continue to do that. They will not hit the threshold of a full peanut by the end of the year. They’re really, really microdosing this in the true sense of the word. ”
Kari clarifies: after a couple of weeks, you’ll be up to 40-60 mg There are certain steps of this where you don’t have to increase by 25%, where you can go higher/ steeper So by the end of the year, the dose is about 1-2 peanuts
Also remember that a lot of people have more than one allergy , and they had to work this out scientifically to go low and slow, but within reasons so that they could get the immune system to flip within a year That way if the patient didn’t want to continue with therapy, they would be safe for an accidental ingestion of that food
There are certain steps of this where you don’t have to increase by 25%, where you can go higher/ steeper
So by the end of the year, the dose is about 1-2 peanuts
That way if the patient didn’t want to continue with therapy, they would be safe for an accidental ingestion of that food

How do you evaluate the therapy?

Are you looking at the IgE, IgG level? Are you simply doing this based on the absence of symptoms in the presence of the administration?

Blood biomarkers Thanks to a lot of pioneers and patients in those trials They were taking blood every 2-3 months and looking to see when the humoral immune system started to switch [from making IgE to IgG antibodies]
They used those biomarkers to readjust and recreate the regimen so that you could go low and slow in the beginning
By about 3 months, they knew the “muscles” were starting to change, so they could hike up the dose a little more By six months, even more By a year, the immune system had switched
It took a lot of time and effort and blood draws from those original pioneer patients to give us the science by which we could perfect this regimen It’s not perfect yet, but it’s much better than it was 10 years ago
Thanks to a lot of pioneers and patients in those trials
They were taking blood every 2-3 months and looking to see when the humoral immune system started to switch [from making IgE to IgG antibodies]
By six months, even more
By a year, the immune system had switched
It’s not perfect yet, but it’s much better than it was 10 years ago

By the end of a year

Patients may not want to continue with frequent immunotherapy injections

Is it safe to assume they may never be able to eat nuts, but if they accidentally ingest a nut here and there, that they’re going to be fine?

They try to get patients up to 600 mg by the end of a year, and that’s what the FDA thinks is the threshold for accidental ingestion

Oftentimes, people say, “ I’m done. I really don’t want to have to do this every day. Can you please tell me if I could take my dose weekly or if I can take it every other day? And what dose is safe enough? ”
For maintenance , they try to get them up to 2 peanuts a day They don’t want to have to take a nut every day, but they kind of have to because we don’t know what will happen if you stop
With long-term follow-up, we are learning who can stop therapy and who might not be able to stop therapy
They don’t want to have to take a nut every day, but they kind of have to because we don’t know what will happen if you stop

In general, it’s much better to take 1-2 nuts every day after you finish your therapy with a doctor

Do they ever transition to the point where they can do this as outpatients on their own or do they always have to do this in a doctor’s office?

After 6 months to 1 year, if people get up to 1-2 peanuts a day (or hazelnuts or glasses of milk), then they can do this at home and just let the doctor know how they are doing

Are people undergoing this therapy outside of clinical trials yet?

Yes, and that’s been going on for a while
We were very careful to say that if you do decide to do it in an outside clinic, try to get your health insurance to approve
We want to democratize this We don’t want it to be only available to certain populations because everyone gets food allergy and sees no boundaries in terms of ethnicities or socioeconomic status
People of color have a much higher rate of anaphylaxis unfortunately because of access to healthcare
There are clinics that are offering this For example, Latitude in New York City and San Francisco now offer specific regimens that are based on science and evidence to be able to offer therapy There are unique clinics out there that are specializing in food allergy care to be able to help patients based on scientific methods
We don’t want it to be only available to certain populations because everyone gets food allergy and sees no boundaries in terms of ethnicities or socioeconomic status
For example, Latitude in New York City and San Francisco now offer specific regimens that are based on science and evidence to be able to offer therapy
There are unique clinics out there that are specializing in food allergy care to be able to help patients based on scientific methods

What fraction of patients who continue this protocol get to the point where they completely shed the allergy altogether and at some point will go on to eat as many peanuts as they want?

Kari always starts any conversation with a patient by saying this is possible
Some patients just want to be able to eat 1-2 peanuts for the rest of their life and know they’re not going to have an accidental ingestion They’re willing to do that They believe that is the “cure”
As a doctor, Kari pushes her standards a little higher: a cure should be eating ad-lib and not having to worry at all
In that category, if you take the dose for at least 2 years, you have a 20% chance of being in the cure category 20% chance of being “cured” after stopping treatment after 2 years 60% chance of being “cured” after stopping treatment after 5 years
Time on dose matters; it’s all recalibrating/ reeducating the immune system
Many people ask Kari, “ Are there some people that are refractory? ” You’ll now that term because of people that are refractory to cancer therapy But in allergy, there’s no refractoriness per se
If sometimes people have too much abdominal pain or they have too many hives or their asthma gets worse every time they have the dose that’s where she’ll say, “ Hey it might not be worth it. There’s too many side effects here, this bothers you too much .” We try to decrease the dose so that we personalize it for them But some people just say, “ This is too much now I really don’t want to go through it .”
But in general, if you stay with it, you’ll get the benefit from it
They’re willing to do that
They believe that is the “cure”
20% chance of being “cured” after stopping treatment after 2 years
60% chance of being “cured” after stopping treatment after 5 years
You’ll now that term because of people that are refractory to cancer therapy
But in allergy, there’s no refractoriness per se
We try to decrease the dose so that we personalize it for them
But some people just say, “ This is too much now I really don’t want to go through it .”

What percentage, if any, of people going through the clinical trials required epinephrine during the administration of the immunotherapy?

Nowadays it’s very rare, about 1 in 100,000

Is there any allergen that is not amenable to this type of therapy?

This goes back to the elemental nature of the immune system, and this work with any protein
It’s very rare that the allergen is not a protein One example is the sugar alpha-gal This is rare, occurring in the southeastern part of the US, associated with a tick bite [ alpha-gal allergy ] Kari doesn’t think this regimen will work with alpha-gal allergies because that’s a sugar
One example is the sugar alpha-gal This is rare, occurring in the southeastern part of the US, associated with a tick bite [ alpha-gal allergy ] Kari doesn’t think this regimen will work with alpha-gal allergies because that’s a sugar
This is rare, occurring in the southeastern part of the US, associated with a tick bite [ alpha-gal allergy ]
Kari doesn’t think this regimen will work with alpha-gal allergies because that’s a sugar

Right now, there’s nothing they have not been able to desensitize a patient to with food allergies

Can immunotherapy work for environmental allergens like pollen? [1:24:00]

Environmental allergens

In Austin there is a thing called “cedar fever”
The cedar trees give off a ton of pollen sometime between November to January
People affected can’t function without Benadryl and Zyrtec
Peter has asked around on behalf of friends to see if there are immunologists and allergists that have an immunotherapy regimen, and he can’t find any

Would “cedar fever” be an easy thing to address?

Cedar allergies are interesting, because the cedar protein itself is something called a protease You can start to grade proteins; it’s a little weird But cedar allergies are very serious
Yes, there are people that have developed immunotherapy for cedar It’s the same rubric to desensitize to it, although it takes a lot of care [and maybe that’s why providers are hard to find]
Cedar allergies are something just like other tree allergies, they can give you lots of mucus and asthma
You can start to grade proteins; it’s a little weird
But cedar allergies are very serious
It’s the same rubric to desensitize to it, although it takes a lot of care [and maybe that’s why providers are hard to find]

Kari breaks immunotherapy down to proactive therapy and reactive therapy

Reactive therapies are all those antihistamines people need to take
Proactive therapy is the immunotherapy to readjust your immune system

But you need both

Air pollution: impact on health and tips for reducing your risk [1:25:30]

Air pollution: tell folks what a PM2.5 is and why somebody should care

10 years ago, Kari didn’t understand all of the PM2.5 jargon either

“ This is something that we all need to learn now, every single one of us, even if we’re in a research station in Antarctica, because air pollution unfortunately is rising ”‒ Kari Nadeau

There are no boundaries, when wildfire smoke happens in Australia, it can circumnavigate the world within 4 days

PM2.5 is a way that we measure to air pollution, but it’s not everything in air pollution, it’s the particles in air pollution that are 2.5 microns in size

Now you think, well what in heaven’s name is that? 2.5 microns? Think of a little red blood cell, that’s 1 micron (1 𝜇m) So, you think about particles that are basically about twice the size of a red blood cell and those are floating around in the air
They come from partially combusted fuel/ combusted fuel from our cars (if you don’t have an electric car) Combusted fuel from industry when it breaks up petroleum (when it breaks up any kind of product, wood fire as well), little particles escape into the air and those particles are not what you see as soot on your car They’re not what you see as brown dust on your house
These are particles that are so small, they continue to be aerated and they can float in the air around the whole world And they’re so small that they can penetrate into our lungs
Think of a little red blood cell, that’s 1 micron (1 𝜇m)
So, you think about particles that are basically about twice the size of a red blood cell and those are floating around in the air
Combusted fuel from industry when it breaks up petroleum (when it breaks up any kind of product, wood fire as well), little particles escape into the air and those particles are not what you see as soot on your car They’re not what you see as brown dust on your house
They’re not what you see as brown dust on your house
And they’re so small that they can penetrate into our lungs

Why do we care about that size, 2.5 microns?

Because it can get through our lungs and into our blood
It’s dangerous also because PM2.5 as a defined measure of air pollution has about 200 different chemicals in it
And of those 200, some of those are what we call volatile organic compounds These are compounds that you smell when you smell markers like xylene or in the old days, mothballs, naphthalene These are chemicals that are not good for the body They are from combusting fuel If any one of your listeners is a chemist, these are what we typically call six-membered rings They’re organic chemists’ nightmares because they smell horrible (Kari didn’t like them when she was doing organic chemistry when she was a student) She doesn’t like them now because now she knows what they can do to your body
Volatile organic compounds can: cause cancer, increase asthma, increase cardiovascular disease, stroke
Wildfire smoke is even more potent as an air pollutant than PM2.5
We also measure PM2.5 for wildfire smoke because wildfire smoke basically is biomass burning Unfortunately wildfires aren’t burning just trees anymore; they’re also burning commercial buildings
Comparing what goes up in wildfire smoke to let’s say just diesel from the car (which is bad enough) With wildfires, you’re burning up your upholstery, paint thinners, detergents underneath your sink, shampoos ‒ that’s all going up in the air And that’s also measured as PM2.5 because all those particles are so small they’re also going into your lungs
With wildfire smoke we also have to be super careful
You can look on websites such as AirNow or the NOAA website and know what the air quality index in your region is for the day If it’s in the green zone, great If it’s in the yellow zone, please start wearing a mask
A mask like the one you used to wear in COVID are very important to reduce the risk of those exposures to your lungs Especially for children and elderly patients
PM2.5 is measurable, it’s biologically and medically important
In California they use something called PurpleAir monitors and you can look on the web and it will tell you what the PM2.5 measures in the air We are lucky in the US that our agencies measure PM2.5 on a regular basis so we can map that to our zip codes
These are compounds that you smell when you smell markers like xylene or in the old days, mothballs, naphthalene
These are chemicals that are not good for the body
They are from combusting fuel
If any one of your listeners is a chemist, these are what we typically call six-membered rings They’re organic chemists’ nightmares because they smell horrible (Kari didn’t like them when she was doing organic chemistry when she was a student) She doesn’t like them now because now she knows what they can do to your body
They’re organic chemists’ nightmares because they smell horrible (Kari didn’t like them when she was doing organic chemistry when she was a student)
She doesn’t like them now because now she knows what they can do to your body
Unfortunately wildfires aren’t burning just trees anymore; they’re also burning commercial buildings
With wildfires, you’re burning up your upholstery, paint thinners, detergents underneath your sink, shampoos ‒ that’s all going up in the air And that’s also measured as PM2.5 because all those particles are so small they’re also going into your lungs
And that’s also measured as PM2.5 because all those particles are so small they’re also going into your lungs
If it’s in the green zone, great
If it’s in the yellow zone, please start wearing a mask
Especially for children and elderly patients
We are lucky in the US that our agencies measure PM2.5 on a regular basis so we can map that to our zip codes

Is it necessary to buy a PM2.5 monitor for your home or is looking at one of these databases enough?

Peter points out that there are a lot of PM2.5 monitors you can buy for your home and asks: Do you need to make sure that you don’t have particulate matter in your home due to a leaking stove (that would probably turn up as carbon monoxide) Do you need to know what the level is outdoors because that might be the day you choose not to do your 10-mile run if it’s a red day?
Kari replies that all of these things are important
If you know you have to be outdoors for work, for 8 hours no matter what, and the air quality index is 100, then you should wear a N95 mask
Do you need to make sure that you don’t have particulate matter in your home due to a leaking stove (that would probably turn up as carbon monoxide)
Do you need to know what the level is outdoors because that might be the day you choose not to do your 10-mile run if it’s a red day?

Will a N95 sufficiently prevent PM2.5 from getting in?

Not perfectly, but at least it reduces the risk
No mask completely reduces those small organic molecules (those six membered rings from getting through the mask), but at least it’s better than nothing
Kari tells her patients, “ Please don’t exercise during any air quality index that’s greater than let’s say 50. ” Because even though they might not feel it during the hour that they exercise outside, it definitely affects their immune system
There were studies done in London for example, where people would exercise out in the streets that had a certain air quality index And in London you can actually do this because there’s micro PM2.5 measurements in Hyde Park versus in Broad Street
Because even though they might not feel it during the hour that they exercise outside, it definitely affects their immune system
And in London you can actually do this because there’s micro PM2.5 measurements in Hyde Park versus in Broad Street

They did this research and they knew that even if people exercise out for one hour in polluted air (versus clean air), their immune system changed for a whole day based on that one hour of exercise

Indoor air is also very important More than 90% of our lives are spent indoors (for the typical US citizen)
So having a Purple Air monitor indoors is helpful, especially if you live in a place with lots of wildfire smoke or air pollution Because you can’t assume that your air pollution is being filtered appropriately and you can’t assume that you’re being protected because oftentimes you can’t smell this and you can’t see it It is so small that you need a special detection monitor to know if it’s there
Now if you do have bad indoor air, you can buy a MERV filter (13 or higher, don’t buy a MERV 7 or 8) You can buy a filter in your air conditioning or central air or you buy a standup filter to reduce the exposure
All these things are available to people, and in certain states they are available freely for families that can’t afford them
More than 90% of our lives are spent indoors (for the typical US citizen)
Because you can’t assume that your air pollution is being filtered appropriately and you can’t assume that you’re being protected because oftentimes you can’t smell this and you can’t see it
It is so small that you need a special detection monitor to know if it’s there
You can buy a filter in your air conditioning or central air or you buy a standup filter to reduce the exposure

Let’s say you buy the Purple air monitor or figure out that you liver in an area where there’s enough pollution outdoors that it can easily get indoors

Option #1 is to get a HEPA filter for the house
Option #2 is to get a MERV 13 (or higher) filter for your HVAC Don’t buy a MERV 7 or 8 See the figure below
Don’t buy a MERV 7 or 8
See the figure below

Figure 7. MERV scale of effectiveness of air filters . Image credit: Wikipedia

MERV 13 reduces all of the major PM2.5 as well as pollens as well as other chemicals’
But you need to change them often, because they’re getting clogged up
Kari doesn’t work for PurpleAir, but you can buy any of these monitors that can monitor external outside air and indoor air You can buy them and get to know the difference
You can buy them and get to know the difference

General advice

It’s good to ventilate your home
You don’t want your home to be collecting its own toxins, and that can happen if you have a gas stove or a wood stove
In general, knowing and measuring your PM2.5 is going to be helpful to your health because you can manage accordingly

Do you have a sense of the magnitude of the effect of air pollution on our health?

Peter wanted to include a section in his book on air pollution, but didn’t for a couple of reasons
The biggest reason was he couldn’t get a clear sense of the mortality impact He couldn’t quantify it in the way you can for smoking or obesity
Quantifying the exposure is difficult It’s not like pack years of cigarettes where we can say 40 pack year history versus zero pack year history translates to this much difference in outcome
Kari explains that the WHO just put a report out, the AQLI just put a report out from University of Chicago Kari adds, “P eter, I feel like you are in this incredible position to make this impact with others. You are a trusted voice and because of that comes the privilege of being a trusted voice, but also that accountability and responsibility of knowing all the science. And so what I’ll do is send you this report because it has now been put into exactly those terms and it’s more dangerous than tobacco smoke, because it is so prolific. ” In the first page of this report, it shares with you the context of how pollution has killed about 8-10 million people a year now And that’s attributed directly to air pollution
He couldn’t quantify it in the way you can for smoking or obesity
It’s not like pack years of cigarettes where we can say 40 pack year history versus zero pack year history translates to this much difference in outcome
Kari adds, “P eter, I feel like you are in this incredible position to make this impact with others. You are a trusted voice and because of that comes the privilege of being a trusted voice, but also that accountability and responsibility of knowing all the science. And so what I’ll do is send you this report because it has now been put into exactly those terms and it’s more dangerous than tobacco smoke, because it is so prolific. ”
In the first page of this report, it shares with you the context of how pollution has killed about 8-10 million people a year now And that’s attributed directly to air pollution
And that’s attributed directly to air pollution

What is the final common pathway? Where do we think the actual mortality comes from?

Is the majority through cardiovascular disease, cancer?

Exactly, especially in low to middle income countries, it’s cardiovascular disease and lung disease
In more westernized countries, it’s more associated with stroke, long-term cardiovascular disease, and cancer
Now, thanks to a lot of science, you can disaggregate what deaths are due to air pollution versus what deaths are due to tobacco smoke
There’s a multiplicity of effect here, but now the epidemiologists really have the data, and you can sink your teeth into this data and know that it’s accurate

What happened to Kari’s early patient who died despite using an epinephrine device? [1:37:15]

When you go back to the child who died in the ICU, the child who was your patient zero (mentioned earlier), why did the EpiPen not work?

It had expired; they hadn’t renewed the EpiPen
They hadn’t gone to the doctor for at least 5 years and they assumed that their child had grown-out of the milk allergy Because that’s what people told them would happen
They never got their [child’s] IgE retested
They never went back to their allergist
They still had the EpiPen that had been given to them 5 years prior and it had expired
In addition, it was for a different weight child It was for EPI JR, and he had grown Even if the Epi was not expired, he should have gotten a different dose
Because that’s what people told them would happen
It was for EPI JR, and he had grown
Even if the Epi was not expired, he should have gotten a different dose

It interlaid all these aspects about the fact that you cannot know that what typically happens to a patient is what will happen to you. You need to actually go to a doctor and get your own set of data to figure out how to best manage your disease.

It also taught the lesson: you’ve got to keep updating your EpiPen and make sure it’s renewed and the correct dose

Was there a big controversy a couple of years ago when a company that was selling EpiPens decided egregiously for no apparent reason other than just malicious greed to jack the prices up. Has that resolved and are EpiPens now relatively inexpensive again?

That’s right
That company was Mylan and they were making EpiPens
And that’s why Kari called it an “injectable epinephrine device” because now there’s a lot of them
Thank goodness the FDA other agencies got involved and said this is not right

“ No one should be charged that amount of money for a lifesaving drug ”‒ Kari Nadeau

That’s when generic epinephrine devices started to be made Other companies started to hit the road There’s other devices now that can be used called the AUVI-Q There is also potentially a nasal epi that can be used [FDA rejected it after the recording of this podcast]
Other companies started to hit the road
There’s other devices now that can be used called the AUVI-Q
There is also potentially a nasal epi that can be used [FDA rejected it after the recording of this podcast]

What were they charging for EpiPens?

$400-600 for some of Kari’s patients
Luckily that is now being covered by insurance
Third party payers also need to make sure that they can reimburse for these lifesaving medications

Resources for those wanting to learn more or find clinical trials related to food allergies [1:40:45]

What would you suggest for those people, someone listening or hearing this, who is being blown away by what you’re telling them? Where can they either find a clinical trial or find a nonclinical trial provider, who’s able to walk them down this pathway?

Do a search on clinicaltrials.gov , look under the category of food allergy , and you can find out what clinical trial nearby you is actually ongoing for food allergy therapy
There’s a lot more than there were just five years ago
There’s like 17 companies in this space now, and Kari is really excited about the future

“ There is a lot of hope and promise ”‒ Kari Nadeau

There are more clinics around the country that are specializing in food allergy
One example mentioned earlier is Latitude , but there are others as well
With that in mind, go to your healthcare provider, ask them questions If you feel like they don’t have time or they haven’t really answered the questions in the way that you learned about today, go online and find out about those clinics that specialize in food allergy therapy
Not everyone fits with everyone; so, give it a test See if you like that structure and then you can try
That possibility is there, that reality is there, and Kari hopes everyone tries to undergo therapy
If you feel like they don’t have time or they haven’t really answered the questions in the way that you learned about today, go online and find out about those clinics that specialize in food allergy therapy
See if you like that structure and then you can try

Selected Links / Related Material

Kari’s book : The End of Food Allergy: The First Program To Prevent and Reverse a 21st Century Epidemic by Kari Nadeau and Sloan Barnett (September 2020) | [1:45]

Incidence of food allergies in children : The Public Health Impact of Parent-Reported Childhood Food Allergies in the United States | Pediatrics (R Gupta et al 2018) | [38:00]

FARE ‒ food allergy advocate and education organization : FARE: Food Allergy Research & Education (2023) | [1:05:15]

Food allergy clinic : Take Control of Your Food Allergies | Latitude: Food Allergy Care (2023) | [1:20:30]

Websites to check air quality in your region : [1:29:15]

2023 AQLI report : AQLI: Air Quality Life Index Annual Update | University of Chicago (M Greenstone and C Hasenkopf 2023) | [1:35:30]

Role of the skin in development of food allergy : Epicutaneous sensitization in the development of food allergy: what is the evidence and how can this be prevented? | Allergy (H Brough et al 2020)

Characteristics and etiology of food allergy : Food Allergy from Infancy through Adulthood | The Journal of Allergy and Clinical Immunology (S Sicherer et al 2020)

People Mentioned

Christopher Walsh (was the Hamilton Kuhn Professor of Biological Chemistry and Molecular Pharmacology, Emeritus, at Harvard Medical School and Kari’s Ph.D. advisor) [5:30]
Richi Gupta (Director, Institute for Public Health and Medicine (IPHAM) – Center for Food Allergy & Asthma; Professor of Pediatrics (Advanced General Pediatrics and Primary Care), Medicine (Allergy and Immunology) and Preventive Medicine at Northwestern University) [38:00]
Kimberley (Kim) Yates (Founder and CEO of Latitude Food Allergy Care) [1:05:15]

Kari Nadeau earned her B.S. in Biology from Haverford College and her M.D./Ph.D. from Harvard Medical School. She completed a pediatric internship and residency at Boston Children’s Hospital and a residency and fellowship in allergy, asthma, and immunology at Stanford-UCSF. After this, she joined the faculty at Stanford Medical School. Currently, Dr. Nadeau is the Chair of the Department of Environmental Health at Harvard School of Public Health and John Rock Professor of Climate and Population Studies. She practices Allergy, Asthma, Immunology in children and adults.

For more than 30 years, Dr. Nadeau has devoted herself to understanding how environmental and genetic factors affect the risk of developing allergies and asthma, especially wildfire-induced air pollution. She has published over 400+ papers, many in the field of climate change and health. Her laboratory has been studying air pollution and wildfire effects on children and adults, including wildland firefighters. She oversees a team working on air pollution and wildfire research along with a multidisciplinary group of community leaders, firefighters, engineers, scientists, lawyers, and policy makers. Dr. Nadeau was appointed as a member of the U.S. Federal Wildfire Commission in 2022. She is also a member of the National Academy of Medicine and the U.S. EPA Children’s Health Protection Committee.

Dr. Nadeau co-founded Before Brands, IgGenix, alladapt immunotherapeutics, and COUR Pharmaceuticals. At Stanford, she started the Sustainability Health Seed Grant initiative as well as the Climate Change and Health Equity Task Force and Fellowship program. [ Harvard ]

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