eSignature Food Allergy Chart Made Easy

E signature food allergy chart

- What's up everybody? Dr. Mike here, welcome to another episode of the Wednesday Checkup. I'm joined today by a very special guest, Dr. Dave Stukus, who's gonna teach us everything we need to know about allergies. Is that correct? - That is correct. - Tell us a little about yourself, what do you do, what does it mean to be an allergist? - Yeah, so I am pediatric allergist, which means after my pediatric residency, I did special fellowship training to learn all about allergies and immune system. I work in Columbus, Ohio at Nationwide Children's Hospital, where I serve as the director of the Food Allergy Center there, and I do a whole lot of other things in the academic realm as well. And I love being an allergist because you know, unfortunately, allergies affects about 30 to 40% of the population. It's something that affects kids, adults, and it's chronic and sometimes lifelong, and we're talking about you know, hay fever, allergic rhinitis, food allergies, eczema, medication allergies, asthma, you name it, so it's very rewarding and I can't wait to have a great discussion. - Cool. Something you talk about quite often is that we have in our public perception a misunderstanding of what an allergy truly is. Let's talk about that. - Yeah, so I get very picky about the terms that I use because they are very important. So when we talk about an allergy, an allergy is when a body, somebody's body forms and immune response against what's called an allergen, antigen, protein, we're talking about anything from dog dander to birch tree pollen to peanuts or medication. When your body forms an allergic response, you form this antibody called immunoglobulin E or IgE. When you have this IgE against the allergen., every time you're exposed to that allergen, your body will produce a reaction, because the IgE will recognize it, it unlocks the allergy cells in both the skin and throughout the body, releasing chemicals that cause the traditional symptoms such as itching, you can have sneezing, congestion, cough from a respiratory standpoint, in the skin, you can have hives or swelling, you can have vomiting, nausea, we can have a severe allergic reaction called anaphylaxis if you have a food allergy, medication allergies, things like that. So when we talk about allergy, we're very specific because that's an immune response that's gonna cause symptoms every time you're exposed to that allergen. - People oftentimes throw around the word sensitivities, intolerances, and they try and group them in with allergies. But you say that's not appropriate, why is that? - Yeah know, those are very different things, and it's extremely important that people understand the differences. So again, if you have an allergy every time you're exposed, for example, if you have a milk allergy, you won't be able to eat cheese or yogurt or ice cream or drink milk because you'll have symptoms every time. However, if you have an intolerance that's not due to the immune system that's really difficulty with digestion. The most common example as you are all aware is lactose intolerance, you either lack the enzyme to digest the simple sugar lactose or the enzyme isn't working very well. If you eat foods high in lactose, which is a simple sugar found in dairy products, you can't digest it. So it travels through your intestines and it causes a lot of discomfort such as bloating or diarrhea, constipation things like that. And then we have this term sensitivity, and this is really not a well defined term, there's no you know, concrete, medical definition that says you have a sensitivity to anything, but people often attribute this term to a whole host of conditions, but we don't really know what it means. There is a condition such as non-celiac gluten sensitivity where you don't have celiac disease, which is an autoimmune condition where you eat gluten found in wheat and other products, and your body actually attacks itself, and you can have very severe symptoms, but non-celiac gluten sensitivity is more difficulty with dIgEsting it. Other than that it's a really nebulous term that has no great definition, but people will apply it to a whole host of conditions, which it really has no evidence to support. - Sure, and what people need to understand is the danger of having celiac disease is because you're activating your immune system and it starts attacking your own cells, other problems can come up, lymphoma, cancer, all these things that actually cause a problem for you, as opposed to lactose intolerance, well, yeah, you're not gonna have a great time going to the bathroom, but the danger is quite limited there. - And you know, the interesting thing with these intolerances is, they may change over time, so if you get a gastroenteritis or a stomach flu, you may not be able to digest many different foods until your intestines heal and things like that, so you can have these temporary intolerances or maybe more quantity related. So milk allergy, can't eat anything with dairy at all, lactose intolerance, you may be able to eat some cheese every once in a while, you just can't drink milk. - Food sensitivity tests. Oh man food sensitivity tests. That's actually how you and I started talking 'cause my patients come in, they say what they want to get tested, they have very obscure or nonspecific symptoms like fatigue, brain fog, and someone mentioned to them that they should do a food sensitivity test. What's your thought? - Yeah, there's a series called The Choosing Wisely series that was started by the American Board of Internal Medicine several years ago and they partnered with different specialties and what they do is they basically put out, you know, warnings for patients and physicians, these are the tests or treatments to avoid 'cause they're harmful or not backed by evidence. Number one on the list from The American Academy of Allergy, Asthma, Immunology is don't perform IgG testing, or indiscriminate IgE testing. So IgE tests for food allergy or screening tests either. And the reason it's number one is because IgG, which is what these food sensitivity tests measure, is not a test of sensitivity or allergy or intolerance, it's a memory antibody, - Exposure. - We talked about that. Exposure, right. The normal body, the normal human response to eating foods is you will produce IgG 'cause you say, hey, I recognize you, it's a memory antibody. But a lot of companies are touting these food sensitivity tests that measure the specific IgG towards foods, and then when the results come back, they're all reported as elevated or indicative of a sensitivity. And what rarely gets you in the first place is it's like going to the fortune teller. You throw some vague things out there and eventually you gonna find somebody that says that's me. So they take this nebulous term called food sensitivity, and they apply it to things that any human can experience. Acne, dry skin, poor sleep, fatigue, muscle cramps, brain fog. - Leaky gut. - Leaky gut, that's me, I get bloated after a certain meals, well did you eat three bowls of pasta, you know things like that. So they hook you by saying, Can you have a food sensitivity based upon these vague symptoms, take our test or we can scan you for up to 200 to 400 different foods, give you the report back everything is detectable because that's what happens when you eat certain foods, some levels are higher than others and then it can lead to extremely restrictive diets. And you know, people are becoming obsessed with the food that they eat, and they're scanning labels and, and they're really making a hard on themselves to find foods that they can eat and avoid. - Anxiety provoking, when you're eliminating certain food groups in their entirety, you can have vitamin deficiencies, nutrient deficiencies, you may be missing something truly, like, I don't know, like low thyroid hormone because you went for a food sensitivity test 'cause you were tired, you could be anemic, you could have a cancer going on, you could be suffering with depression, there's so many things that can be missed, when you say, Oh, well, this company pitch this food sensitivity test much better than my doctor did for other medical things that are going on. These doctors aren't trying to pitch you something, they're trying to genuinely help you, we're not trying to get more money, I mean, in the huge majority of cases obviously. - Yes, and but you also have medical professionals that have these, so dietitians and we have naturopath and chiropractors and even well intentioned physicians and others that don't fully understand what these tests can and can't do. But they're not validated at all, there's no evidence to support their use whatsoever unless you want to find out foods you've eaten. - And you've actually told me before we went on camera that you had a little journey taking one of these, what happened, what was your experience like? - I was curious, I want to know what are people doing and what kind of information are they getting. So it's an easy test to do, you take a little sample blood from your finger and you send it back and get your results about five to seven days, a couple of things stood out. So one, everything came back you know at some level of detection and said I have a sensitivity to 79 different foods. Some high, some moderate. Two, the reason I knew that it was bogus was it said that I'm highly sensitive to cottage cheese. - Okay. - And here's why I know this. I think cottage cheese is disgusting. (DR. Mike laughs) My personal viewpoints, I'm not eating on a regular basis it certainly not causing brain fog or anything like that. Unless of course I have brain fog and I'm forgetting I'm eating it. - Yeah. - Number two, there's no normal range. We actually don't know what a normal range is for any of these specific foods. If we extrapolate to IgE testing, we know that specific food testing for IgE in the blood, there's a range, and some numbers mean different things for different foods. While on these food sensitivity tests, they just say anything detectable is bad. - Yeah, so this is really critical here. So when we do a blood test, we know that there's normal ranges, and let's use an example of anemia. If we are looking at a patient's hemoglobin level, which is our indicator of whether or not someone is anemic, we can say between this number and this number is normal, if you're past it, something could be going on, if you're low, you're anemic, something can be going on. When we do IgE testing, which is the true allergy testing that you need with a thorough history, that's the allergy tests that we would doing in an allergist office. There we know the range of what is normal. Now, the way we know that is through validated studies. When we say validated studies, these are evidence based randomized controlled studies that have given us guidance for what's normal. When we do these IgG tests that are the send out test from marketers, they just make up whatever they want, right? There's no real validation for this. There's no randomized controlled studies, any studies they do on their own, who knows what they're doing right? - Right, right. - It's totally with the (mumbles) out there. - It is. One other thing that struck me was there's no unit of measurement. - Okay (laughs) - Yeah it's important. I don't even know what they're measuring. - So it's like a random scale. - It was, yeah it was a decimal point up to three decimal place. - Okay, interesting. - It was fascinating, yeah. - Okay, I love that they do that. And did it, did you change your guidance in any way of what you're eating? Did you see any truth to it or? - No, you know, I took the quiz ahead of time as well, and there were some vague things that you know, every once in a while my skin gets a little dry a little bloated and things like that. - And then you're realizing, oh, my God, this is how they get people. - Oh yeah, they're not validated, they cost a lot of money, they can distract you from what may actually be going on, and, you know, this is not us saying that people cannot have symptoms from eating foods, absolutely, yeah, and some people can get very sick from eating specific foods. This test won't tell you that, I recommend talking to your personal doctor, and sometimes even a trial elimination period can help. You take the food out of your diet, do those symptoms disappear? And then if you eat the food again to they come back again? It's time consuming and tedious but that's really the best way to go about it. - For sure. If you're having a patient referred to you and they're there for allergy testing, what are the routes that you can take to find out if someone has an allergy? - Yeah, so the history is the most important part. So we always want to take a very detailed thorough history to see if the symptoms and the timing line up with a potential allergy. And then, you know, let's talk about food allergies, for instance. We have three ways of testing for food allergies. In the office setting is skin prick or scratch test, we apply a drop of the liquid allergen to the skin, usually on the back or on the forearm, we gently scratched the surface, if your body has that IgE antibody preform to that allergen it unlocks the mast cells in the skin and releases histamine. Histamine causes itching and hives. We wait 15 minutes. The size of the hive indicates the likelihood that you actually have an allergy, based upon the history that you provide. - And not the strength of the allergy. - That's right - that's the important one. - Yes, thank you. So no allergy tests can tell you how severe your allergy is. So there are people walking around saying, I was told that I have a deathly peanut allergy based upon my test, that's not how the test works, so that's thank you bringing that up. - That's really important. 'cause a lot of my patients do say things like that. - Yes, and they're told that by well intentioned medical professionals who don't understand these important nuance. - Of course. - We blood tests. We can measure the level of specific IgE in the blood. Generally, the scale goes from zero to 100. The higher the number in the blood just indicates more likely that allergy is present, also doesn't tell us about the severity. There are tons of false positives on skin prick and blood testing, so we wanna only test for the allergens that the history really indicates may be a cause of allergy, and if the symptoms don't line up with allergy, we often don't have to do any testing at all. And then lastly, the best test especially with food allergies, is an oral food challenge. Your history is sort of indeterminate, you're testing is kind of wishy washy, let's actually have you eat some of it and gradually increasing amounts in the office setting where you're supervised, very safe to do it that way, and that's the best way, 'cause again, if you have a true allergy, you should have symptoms every time you eat it. - Let's say finances out the window, it doesn't matter, you have unlimited money, unlimited resources, which of these three do you do first? - To be honest with you, I would go straight to challenge. - Okay (laughs) - Yeah, 'cause I think that it's a safe thing to do, you know, we're not gonna be, you know, harmful if somebody just had a severe life threatening reaction, - Of course. - We're not just gonna give it to them again. So that's really the best test. - Okay. - 'Cause we get so many false positives on the skin testing, blood testing. I have patients that come to see us every week, and they have a whole battery of tests, and sometimes I'm handcuffed and there's nothing I can do, and I say, I don't I wouldn't have done this in the first place, these levels are really high, I think that you may be a risk and other than, you know, feeding it to you again, which some people, you know, they're nervous to do and rightfully so, that's all we can do about it. - When we talk about allergies, one of the mainstays of treatments we just discussed was desensitization, right? What is that in theory that's introducing small amounts of something where it challenges the body but not too much, so after a while it becomes more accustomed to it. - Right. - Right, would you say that's the best solution. - Yeah, you shift from an allergic response to a tolerant one. - Exactly. Something that's happening in social media, and I know you're an expert in social media you have published on it, you're frequently on Twitter, that's how you and I have met, we see that there's this thing of avoidance coming out when it comes to mental health anxieties, depressions, treatments, and people are oftentimes worried of stepping outside their comfort zone. They're worried about being uncomfortable. Would you say that there's some crossover and at least my light way of thinking, perhaps in yours as well, of desensitization to allergies, and desensitization to certain fears, to certain anxieties that we experience and the more we hide from those things, the more that it can become a problem, let's say you. - Yeah, I was wondering whether you're gonna go. - Yeah, it's kind of an interesting (mumbles). - Yeah, I agree with you, yeah So what you're kind of describing cognitive behavioral therapy. - Yeah of course. - That's something we do with patients who have food allergies, extreme anxiety with the food allergy - Okay. - Their perceived risk is way up here, where the actual risk is way down here. And how do we actually get those two to coincide. So we all get trapped on our own heads, and we think, you know, the what if scenario, what if I do this? What if I'm exposed to this and the person before, you know had this on their hand? And what if I touch it? What if I put in my mouth? And what if I start to have a severe symptoms? And what if I don't have my epinephrine available, the what ifs. Those dots rarely actually connect in real life, but in our minds, it can be really severe. So one way to overcome that is through exposure. So I can tell you what if by exposing you to it. And with food allergies, so one thing we do some something called proximity challenges. I'm deathly afraid that if somebody near me has peanut butter or peanut butter gets on my skin that I'll die. I can show you in the office setting in a very controlled manner, if I put some on your skin, nothing bad will happen. So we take away the big bad fear of the what if by small exposures over time. - Because the what if, most of the time, is more dangerous because it causes anxiety, panic, (mumbles) cardio, symptoms that are true, but from a thing that's actually not that great of a risk to you. - Yeah, and in today's world with constant click bait headlines and social media, the what if scenarios get amplified so much, and it offers an unfair weight because the what ifs now outweigh the likely. And it's not fair for any of us because it's really hard to navigate the world, you know, on red alert at all times. - Of course. That's why I think it's really important to have a quality doctor that you trust, where you can ask what risks are there, should I be worried about these things? "Cause for example, if you come in with indigestion as a 60 year old gentleman with high cholesterol, high cardiac risk, you know, we should be thinking red flags for heart attack, because those things can be lethal. So in some instances, you should be thinking worst case scenario, in some, like you mentioned with peanut dust being in a general vicinity, we shouldn't. And I think having a guide, like a quality physician is really important in that scenario, would you agree? - I agree, and actually this something I'm sure you can relate to. So when we were medical students, you're on red alert, you never know like, does this patient have, you know, severe cancer? Am I gonna miss it? And then after exposure and you see 10,000 people with some variation that you learn to know, okay, I don't need to be on red alert. And you also learn to recognize the red flags. - Let's go through a practical example. This may not be 100% useful to everyone at home, but really useful to myself and maybe if there's other family medicine physicians watching. Let's say, I refer patients to you that I suspect may have an allergy for further allergy testing, 'cause I'm not comfortable ordering specific tests. They come to you you find out that they're having a food allergy to apples, I don't just given a random example. The test says yes, positive for apples. What steps you take there, what do you do now? - Yeah, so thank you for referring (laughs) so you know, I would I really want to caution any medical professional, if you're not comfortable providing the necessary education for patients who have food allergies in regards to avoidance measures, risk from reactions and long term prognosis, then, you know, you shouldn't be doing allergy testing. There's a lot of false positives that we talked about that come back with these, so that's what we do. When we when we feel this somebody has a true food allergy, we counsel them, and we say you can navigate the world, all we want you to do is really focus on trying to avoid ingestion of it. You do have to read labels on packaged products, the most common food allergens will be cow's milk, wheat, egg, soy, peanuts, tree nuts, fish and shellfish, those by law in the United States are mandated if a food contains any of those ingredients, it has to state it very clearly on the package, so we teach people how to read labels. We teach people how to discuss with food handlers at restaurants and bakeries and ice cream parlors and say, I'm allergic to this food, can you guarantee that whatever you serve me doesn't have any cross contact through utensils or things like that. And then we talk about risk because really, the greatest risk for having a severe allergic reaction comes with ingestion. So we want to focus on trying to prevent that as much as we can. Casual exposures such as you know, if you had a peanut allergy and I were shelling peanuts right here eating right now, it'd be extremely unlikely to cause any problems for you at all, let alone a severe allergic reaction. So, anxiety associated with food allergies is very real, we can prevent a lot of that or at least help lessen some of that, at the time of initial diagnosis by giving the proper education help people understand true risk, and not take unnecessary extreme measures to avoid allergens, because from unlikely exposures. And then lastly, you know, we want them to be prepared because accidents do unfortunately happen. So they should have an epinephrine auto injector, they should be taught the signs and symptoms of anaphylaxis and when to use it, and we practice. We have training devices for the different devices that are available, and we practice in the office setting ones without needles of course, and then we get them comfortable with that. And then we revisit this every time we see them to make sure that they're comfortable and managing and avoiding their allergies. - If you are aware that you have a food allergy and you have been prescribed an epi auto injector, please carry it with you number one, and number two, make sure that it is not expired. Now I've done a segment before on expired medications that if you have some over the counter meds at home and their year expired, they're probably still good anyway, but when it comes to life saving medications like insulin, like epinephrine, those need to be treated as such. Their life saving medications, you can't use medications or you shouldn't unless there's obviously extenuating circumstances in an emergency. But please carry your medications. We often talk about making sure that we protect environments kids don't have access to peanuts that no one on a plane is eating peanuts. But really the most important thing is to have the medication that you should be having with you. Would you agree with that? - Oh, yes, absolutely. So the number one reason why people with food allergies can get into trouble and have severe reactions that don't respond very well is they don't have their epinephrine with them or a lot of times that they have it with them, they don't use it, 'cause they're afraid from the needle. So that's one thing we counsel. Epinephrine is the only treatment for anaphylaxis. Anaphylaxis is a rapid onset severe can potentially be life threatening allergic reaction. Epinephrine treats all the symptoms, hives, wheezing, difficulty breathing, you know low blood pressure, Benadryl and histamines do not treat anaphylaxis. Epinephrine works fast, it treats all the symptoms and it can make you feel better right away. So if you have been prescribed it, find a way to have it with you at all times, and then use it if you feel it's necessary. - Especially if you're on an airplane or the Atlantic Ocean. If you haven't seen that story I'm linking that down below. I was on an airplane and someone went into anaphylactic shock, didn't have their EpiPen, they also weren't aware of their allergies so to be fair, but we had to act quickly. (bass thumping beat)