SIO401: Dr. Steve Proper on the Science of Food Allergies

Transcript

This transcript was generated automatically and may contain errors — the audio is the record.

0:00:16 Thomas: Hello and welcome to Serious Inquiries Only. I'm your host, Thomas Smith, and that's your other host, your far more beautiful, good -looking, amazing host, Lydia. I was going to say Heath, but no, I won't. I'll say Lydia.

0:00:26 Lydia: It's fine. Yeah.

0:00:27 Thomas: He's not here. Heath? No. How's it going?

0:00:30 Lydia: Sorry to disappoint you. Pretty good.

0:00:31 Thomas: Yeah. What are you doing here?

0:00:35 Lydia: Oh, well, you know, we had such a good time talking about allergies that we thought, you

0:00:40 Thomas: Not what I would characterize it as, but that's okay. Yeah, fine. Fine.

0:00:42 Lydia: Yeah, I guess it wasn't fun. It was pretty emotional. We have a follow-up episode to talk a little bit more about allergies, but from someone who knows what they're talking about.

0:00:53 Thomas: Yeah, I want to emphasize at the top, this one we did, obviously personal to us. But I appreciate the people who listen and commented and, you know. Food allergies affect a lot of people, so it's not like it's literally just us. But this one is a more let's learn about the science. And if you're listening to this show, I think you're always a fan of learning more about the silence.

0:01:11 Thomas: And so we've got a bona fide expert, Dr. Steve Proper, who is literally what he does. He's a doctor of this essentially. And that's always the best person to learn stuff from. And so let's find out like what the hell's actually going on when Arlo grows a new limb because he touched a peanut or whatever. What is happening? Are What allergies? What aren't they? Are You they different from other things that happen in your body that seem like allergic responses? What's the science there? There are all kinds of fun questions. I think we're going to learn a lot. Well, So, let's get on over to Steve.

But before we do, of course, if you'd like to avoid the annoying ad that is going to happen any second now, like truly whenever we edit, it's going to come in. If you'd like to avoid that, go to patreon.com/seriouspod and get your hands on all the bonus stuff. So no ads, bonus stuff, and the chance to pose questions, by the way. We're doing this every time Lydia's brought it up, but the best we can as calendars allow, as schedules allow.

We are giving patrons a little preview of what's coming up and they have the chance to ask questions and tell us what they want to know from whoever the expert is coming on. I think it's really fun, fun.

0:00:58 Lydia: Yeah. Yeah, yes.

0:02:18 Thomas: This is developing a, yeah, it's like, I just love that this show is a place to learn stuff because I love learning stuff. And, uh, I think we're doing that as a group in a way that's getting better and better all the time. Could be because, you know, Lydia works here full -time now, so things are getting better.

0:02:19 Lydia: It's been super fun. Yeah yeah.

0:02:30 Lydia: Oh, I'm having a blast.

0:02:33 Thomas: With that said, enjoy this auto -add non -patrons.

0:02:38 Lydia: You deserve it.

0:02:40 Thomas: Oh, geez. All right. You're fired. Don't bad mouth the audience. Some people can't become patrons. Just kidding. All right, let's get on over to Dr. C. Propper. We're joined by Dr. Steve Proper. How are you doing today?

0:02:46 Lydia: Oh no, I love you all.

0:02:53 Steve: I'm doing fantastic, Thomas. Thanks for having me on. And Lydia.

0:02:56 Thomas: Oh, our pleasure. Yeah, and Lydia is is here as well. Dr.

0:02:58 Lydia: Yeah, I am.

0:03:00 Thomas: Lydia, Lydia. No, you're not a doctor yet.

0:03:01 Lydia: Not a doctor.

0:03:05 Steve: You could have fooled me with that last episode on food allergy, to be honest. So that was pretty, pretty good. Well done.

0:03:07 Lydia: Aw, thank you. Yeah, it's something that is a big part of my life, so I was glad to hear from an expert that I'm tracking things pretty well.

0:03:14 Steve: Yes.

0:03:18 Thomas: I think we've said on, I don't know if we've set it on the show yet, or uh, just in a bunch of emails, but since, since Lydia is here full time, she's able to go through a lot of the expert submissions that my brain ADHD out of. Cause I was like, well, these are all excellent. And I, I can't, they're, they'RE all good.

0:03:32 Lydia: Yeah, it's too much.

0:03:33 Thomas: Like, yeah, there's too many, if it was like a bunch bunch of bullshit. And then Steve, I could have done it.

0:03:33 Lydia: It's too much. Yeah.

0:03:39 Thomas: All right, cool. But it's like, they're all good. It's amazing submission. So keep it up by the way, everybody, especially because Lydia is now managing that and going through. And don't you talk about this one, Lydia? You What did see in this proposal that brought us here today?

0:03:51 Lydia: It was right after we recorded our food allergy episode that I saw we had a submission from someone who is an expert in food allergies. And I was like, oh, dang it. Just missed it. But I reached out to Steve because some of the things that thought I were interesting there was, you know, yes, we talked about food allergies and Arlo's journey and our journey and some of the history of EpiPens and, you what that experience was like as a parent. But I'm not a doctor. I'm not a scientist. I don't have background in this. I thought it would be nice to bring Steve on to kind it out for us. Right. And bring in the expertise that, you necessarily have. But, about food allergies, like, we introduce them when we introduce them, how that used to look, what kinds of treatments do we have available right now? What does the management of food allergies look like now? And then we have a little bit that Steve and I have gone back and forth on regarding a potentially new treatment that no one knows anything about.

0:04:02 Thomas: Yeah. Wow.

0:04:51 Lydia: So I'm thinking we'll get to that today, too. Too.

0:04:53 Thomas: Well, in the meantime, Steve, do you want to give us basics? I always love hearing kind of how people got into where where they are, or, you know, where you ended up, uh, in in job and all that,

0:04:54 Steve: Yeah. Yeah, definitely. So I am originally from Lansing, Michigan. Um, originally was planning to be just kind of a research guy, and I had the opportunity to do medical school as well as a PhD, so I kind of jumped at that chance because that way I didn't have to make a decision uh, about exactly what I wanted to do, I could just do both and, no, and yeah, it's

0:05:15 Lydia: Wow.

0:05:14 Thomas: Is that common let's say they both sound like really hard work alone, like if you choose one of them.

0:05:25 Steve: Not sane in that way, uh,

0:05:29 Thomas: It's a safe space, it's okay.

0:05:31 Steve: Yeah, well, I tend to choose things that are difficult, so, like, if I have challenging things, I tend to sort of go after them directly instead of avoiding them like most people. But I, I think that for me, it was just the interest in science and kind of merging that with treating people because, you know, I tried the science thing for a while, and as much as I enjoy the science of it, I enjoy talking to people more than, like, my mice and other things that I was working on. So, you it just was something that I came to realize that, hey, you know, seeing patients is probably where I need to be, just to be happiest. But my kind of, after medical school, sent me to do pediatrics, because that's one of the things that you decide when you're, you know, becoming a doctor is, do you want to see adults, or do you want to see kids? And that was pretty easy one for me. Um, I hate adults. Um, I like kids though. Um. But kids are, um,

0:06:18 Thomas: Yeah, we can put our kids on the line, if that'd be, would that be better for you? No, I'm just kidding.

0:06:22 Lydia: Comfortable.

0:06:23 Steve: Maybe, but yeah, so that was an easy call. So I did pediatrics and I, that took me to Milwaukee and, right.

0:06:30 Thomas: Where all the kids are. Yeah. No, I'm just kidding. It's where we keep the nation's children. Yeah. Okay. I'm following. Yeah, I love

0:06:33 Steve: Uh, Uh, exactly. So, uh, after that, I pretty eventually much, figured out through lots of processes that I wanted to do allergy and immunology. And so that took me to Cincinnati Children's Hospital and I was lucky to train there cause it's a pretty cool place. Do lots of research there and that got me exposed to lots of really interesting things.

And so in terms of why I chose all this path, I mean, it's, it's along story, but basically, um, science that I was doing before I went into the allergy side kind of led me that direction. So of the models I was working on with mice had to do with lung injury and with eosinophilia, which is just a fancy word for lots of eosiniophils showing up in tissue. And that kind of lead me towards asthma and allergies.

And so, you time passed and I eventually worked my way here. And what was interesting about food allergy from the perspective of my training was I really kept my eyes too much on food allergy specifically. So it was something that Cincinnati Children's happened to be doing a lot about. I didn't necessarily set off to do a lot of food allergy work. Work.

And just by being at Cincinnati Children's, we just did so many things with peanut oral immunotherapy that it super interesting to me because I got thrown kind of in the middle of it. Kind of my trajectory there in terms of food allergy. And

0:07:50 Steve: Now I'm back at Western Michigan University, which is in a crazily named city called Kalamazoo, Michigan. And we are on the Southwest side of the lower peninsula there. Medical school, which I'm an assistant professor in, is about 10 or 11 years old now. And I mostly just see patients all day. So

0:07:49 Thomas: It. Yeah oh yeah I was just gonna ask so your assistant professor but you see patients, I don't know how any of that stuff works, but

0:08:12 Steve: Get supported through the medical school and lots of people have professorships that are mostly clinical. I do teach immunology to medical students. So that's like one of my other side gigs that I do here. Wear lots of hats in academia, as I'm sure you're my day-to-day on an average day with Dr. Steve, we are seeing allergy patients and I see adults, I see kids, and it's not just food allergy. There's lots of other stuff that So that's what I like.

0:08:27 Thomas: Yeah would love to more about that. I mean I barely know I'm sure I've been told it a a bunch of times, but my brain doesn't keep information like that. But like, do you mind giving us kind of the basics of, some of these allergies to the extent that, you know, I'm sure it's an entire, you Know, education that you've had, like some of the basic, I I'm curious to like, why are they different? How are they similar? It seems like there's a lot of commonalities, but there's also, it seems to be a massive difference in, in they operate. So I'd love any sort of basics you can give us on that would be great.

0:08:46 Steve: So yep.

0:09:07 Steve: It's always good to start with definitions when when you're talking about technical stuff, right? So when it comes to allergies, I think we colloquially use the term allergy to mean a lot of things. And so at 30 ,000 foot level, an allergy is basically an unusual reaction to something that should not cause a reaction.

So not to the standpoint of like an autoimmune reaction per se, but when you are exposed to things in the the world that are not a threat to you, you should not necessarily respond in a particular way. And so that's a really broad definition of allergy. We talk about it in the context of food allergies or things in the environment, like pollen allergies, pet allergies, the really common stuff that a lot of people have, that's more specific type of reaction.

And that involves involves basically something called IgE or immunoglobulin E, which is a type of antibody that our body makes. Once it does that, it can essentially prime our system to recognize that in the future, should we come across it again. We have particular cells in our body called mast cells, M -A -S -T, and they are full of little granules that are packed full of histamine and triptase and other things.

And that's essentially what causes allergic reactions is when those pre -primed cells get tickled again with their allergen, they are signaled to release those granules out into the tissue. Do we have them? Probably

0:10:31 Thomas: Yeah. I was going to say, what's the good the best case all we ever hear and all we ever experience is boy my nose sure is just running for fucking ever because it never ends and seemingly does nothing yeah like what's the best case, is it the kind of thing where like, well, it's like the best, you know, referee, you don't notice those of things, is it like we don't notice times the where that is actually helping us, or what's going on there

0:10:33 Lydia: My throat is so itchy. She.

0:10:32 Steve: Because... Yeah. Yeah. Think the best guess that we have is throughout evolution, we had lots of enemies. Some of of them were things that had venom. So things that stung us or bit us like snakes. It was in our best interest to have some kind of system to deal with that so that we would survive those encounters. And nowadays they mostly provide me with job security, but in terms of why do we have them, right? It's

0:11:15 Thomas: You're in it with big snake, I knew it yeah

0:11:15 Steve: Right. Big venom. Yes, yeah, proteases that get released by these mast cells basically protect us and sort of degrade the enemy proteins that are in the venom that are designed kill to us. And so the mast cells are always battling with venom. And it was just thought that over time we retained those cells because they were useful at one point. And thankfully we're not having snake battles constantly, depending on your life choices, is of course, but you know, you, yeah, yeah. Australians are just a whole new level of, life -threatening to just be there.

0:11:44 Lydia: Yeah, maybe Australia is, but.

0:11:45 Thomas: Yeah. Yeah. They're like, I don't know what Thomas is talking about. We use this every day. Literally every day I'm using these amazing histamines or whatever the hell.

0:11:58 Steve: Some of us have different life goals. That's cool. Yeah, that's why we probably have them. And nowadays we're mostly dealing with they get bored because most of us are not getting bit by things too often. So that's the fundamental mechanism behind things like food allergy or seasonal allergies and that kind of thing. So are there lots of other allergic reactions? Yes. Do we have time to talk about them? Absolutely not.

0:12:22 Thomas: Yeah. Just conceptually, and maybe this question doesn't make sense. Is it always kind of definitionally an allergic reaction? Is that involve your quote unquote immune system? Is it like your immune system responding in a way that's kind of like overboard or

0:12:24 Steve: Yes.

0:12:37 Steve: No, that's accurate. And I think that goes when you dig down a little further to what is considered an allergic reaction, It to be essentially repeatable. So it's not just a one -off thing. It's also mediated by your immune system. And the whole IgE antibody mast cell degranulation thing that I was just talking about, that's one type of allergic reaction.

0:12:57 Lydia: Right.

0:12:57 Steve: Reaction, there's an old way of listing these types of immune reactions, and and they used to call them hypersensitivity reactions. And so the whole IgE thing is a type one reaction, and that involves pretty much histamine getting released, and that's what causes hives. It causes swelling because it dilates your blood vessels and makes them leaky and it causes a bunch of other things. So on a whole body scale, if you're having this reaction, that's what leads to anaphylaxis and, and, you know, loss of blood pressure, which is not good for you.

0:13:26 Steve: And, that is why epinephrine is extraordinarily helpful when you have anaphylaxis, because it is going to tighten up those blood vessels and make them not leaky anymore. It will stop your blood pressure from dropping and sort of do the opposite.

0:13:26 Lydia: Right,

0:13:36 Thomas: So that's interesting. Is that like the best case scenario would be so that you don't spread the venom around your circulatory system or something? Or is it just, is that not right? Like what does that do in the best -case scenario when it's actually working or whatever?

0:13:50 Steve: What histamine is doing locally is it's opening up that tissue so that immune cells can get in there and fight the venom. That may not work to our benefit because it may actually spread some of the venom. When you dilate your blood vessels at a whole body level, that's just not good. That leads to death. So we don't like that. But when it comes to how your body sort of learned this through evolution, I'm not entirely sure that I have a good answer for that.

0:13:56 Thomas: Okay. Sure.

0:14:13 Steve: But, you know, Anytime you have inflammation, you're talking about blood vessels dilating and getting leaky so that those immune cells can go in there and clean up and do their job. And so that's probably what they are, were initially doing.

0:14:14 Thomas: Yeah.

0:14:25 Thomas: I immune system, our body is really like some guy who just fixes everything with duct tape, you know, he's like, ass swelling, I guess, I don't know, fucking, I don't know what the problem is, but I'm gonna try swelling. And, you know, swelling again, you're always doing, I hurt my knee, swelling, I would, like, this has one thing, yeah.

0:14:42 Steve: I mean, if it works, right.

0:14:44 Thomas: Does?

0:14:45 Steve: It doesn't always, yeah.

0:14:44 Lydia: It gets your attention anyway. Way.

0:14:45 Thomas: It? I. Don't know. Yeah. Sure.

0:14:48 Steve: Makes it painful, warm, all of those things you, you learn about in medical school when you learn about how to identify infection and other things. But yeah, no, absolutely, it's other allergic types of reactions, I don't think it's probably worthwhile to go down those Rabbit holes, because I want to keep us on track with, you know, allergies. One of the, one of the listeners had asked you the deal with allergies versus things that look like allergies, and that is a good question, and I think that that, that's where kind of experts come in. It's worthwhile to have a conversation with someone who understands the different types of reactions that you can be having, because there are mimics, right? Of the ones I deal with a lot with food allergy is people who are lactose intolerant.

0:15:01 Thomas: Yeah.

0:15:25 Lydia: Right.

0:15:25 Steve: And that is a totally different mechanism. And that just has to do with the fact that you cannot break down lactose into its component sugars. And rather than absorbing it and using it, it just kind of sits in your gut and it becomes free food for the bacteria that live there. And they sort of go nuts. What non -absorbable sugars like lactose, um, do is they also keep, uh, fluid and water in your Gutlumen. And so it keeps your, your stools nice and soft.

0:15:51 Thomas: What?

0:15:51 Steve: And for a lot of people, it creates a. So, um... Lactose intolerance kind of follows a pretty specific pattern. Is the enzyme that sort of fixes that by breaking apart, part, sugars, those into glucose and galactose, and then you can absorb them and then you don't have problems. But most humans stop making a whole lot of lactase in their gut after infancy, because we're not supposed to be eating so much dairy, but we love it so much, right? So we've developed some sort of adaptation. Oh, dairy is so good, but can it cause problems. And it's very common for even children who older than infants to have lactose intolerance. So that is a very common thing that I talk about in my clinic, like probably every day we're talking about that. So,

0:16:15 Lydia: Yeah. It's that cheese.

0:16:31 Thomas: Are you talking about, in the sense of, like, look, I'm not the lactose intolerance guy, please stop bringing these, these Shitting Kids, kids to my Door.

0:16:36 Steve: Yes.

0:16:36 Lydia: Stop talking to me about all your farts and

0:16:41 Steve: Yes. There was a funny comic, uh, at the start of COVID by another allergist, who's also a comic artist, and he's out of the Chicagoland area. And he made, he made this comic about, it's the start of COVID, we're all like buckling down, getting ready for the pandemic, we're only going in when we need to, you only know, emergencies, and I'm out to just make sure that my allergic patients get what they need. And then the patient, uh, walks in the door and the patient says, so every time I drink milk, I fart, and Just does a face palm, and he's like, uh, we're doomed. So, but yeah, it's, it's common, right. And it, if that's a problem you're dealing with, right? So to judge what your biggest medical issue is, right.

0:17:08 Thomas: Yeah.

0:17:19 Steve: I'm here to provide knowledge and expertise when I can. And, you I've learned anything with science and being a scientist, it's that I don't really everything. In fact, I know very little about a lot of things when you drill right down to it, right, but it's important to know what you know about certain things and that really can help you. So yes,

0:17:37 Thomas: Well, I just think that you and the lactose intolerance guy should get adjoining offices, you know? So you're just like point, point to the door that way. Nope. Not doing it again.

0:17:42 Steve: CF, I feel like I am the lactose intolerance guy. So yeah,

0:17:47 Thomas: Yeah, or that. Yeah just become just vertical integration or I don't know.

0:17:49 Lydia: Just keep a lot of lactate in your office. And then anytime anyone comes over, just send them out with that. You're

0:17:53 Thomas: Yeah Yeah. Oh

0:17:54 Steve: It makes me feel like I should have gotten stock in some sort of lactate product. But an allergist, I see allergies. I also manage things like asthma and immune deficiencies. So it's kind of variable in terms of what I do day to day. But

0:17:59 Lydia: Yeah, yeah,

0:18:09 Thomas: Yeah. What's, going what's on? What's the difference between asthma and like an allergic reaction that manifests in the kind breathing?

0:18:18 Steve: Is also an inflammatory condition. People have different triggers for asthma. So, so asthma is not just the inflammation of your lungs, but it's also basically the constriction of your breathing tubes, your bronchioles and your bronchii. You end up with kind of air trapping because you, the air can get in, but it's harder to get it out and lots of different things can trick.

0:18:39 Thomas: Oh, to get out. Oh, I didn't

0:18:41 Steve: Right.

0:18:41 Thomas: Realize that.

0:18:42 Steve: Yep, wheezing is basically a whistling sound that you hear when you're trying to push a lot of air through a tiny space. And that's kind of what people's lungs are doing when they're an asthmatic and they're having an asthma attack. And most of our acute treatments, so the treatments we do right away to give you relief, are albuterol related, and they are designed to dilate those those bronchi by relaxing the smooth muscle that is around them.

And if you think of the lungs as an upside down tree, it's kind of the trunk and the really big branches of that tree that are affected by this. And they have muscle that wraps around those airways. And so certain things can cause those muscles to become twitchy and irritated and clamp down. A lot of people who have, you know, sports induced asthma, exercise induced asthma, it's really the cold cold air flying in their lungs that triggers those muscles to spasm.

And sometimes they don't really have much inflammation to speak of, but every time they go for a run, they have symptoms. And so we try to pre-treat them with albuterol when they do exercise to prevent that from happening. But other people with asthma have a bunch of allergic triggers and other things that cause a lot of inflammation, and it makes it harder to treat. Asthma is a whole whole nother topic. So no,

0:19:56 Thomas: Was about to say, oh yeah, I had extra induced asthma. And then I realized, oh wait, no, that's just what we thought it was for a while before I realized I just had horrible performance anxiety. Like I would just, the minute there's a competition, I would be like I'm gasping for air and can't breathe, but it's not really that. It's just I get what I don't know what that is. I guess that's not what you do. But like somehow that was misdiagnosed as exercise induced asthma for like five years of my life.

0:20:17 Steve: That is not surprising. Um, a lot of that has to do right with like blood flow and you you can't breathe, it's kind of hard to keep calm, you sometimes it's hard for asthmatics to tell what's the difference between a kind of a panic attack versus, um, an asthma attack. And usually it's a little bit of both. Cause if you've never not been able to breathe. It's, it's

0:20:36 Lydia: Yeah. Exacerbating

0:20:24 Thomas: Hmm. Hmm. Yeah. Right. Yeah. I'm going to be like, I'm perfectly calm. I'm about to die, but It's okay. Don't worry. Totally fine.

0:20:38 Lydia: Itself. Yeah.

0:20:38 Steve: Yeah. Yeah. We're good. I just have to stay calm. So yeah, nothing works better than telling someone having a panic attack to calm down. Yeah, yeah. Asthma, a whole nother topic. We could dive down it for long ways to get to your question though. Like how is, how is an asthma attack different than what's happening when you have like anaphylaxis, right? So probably a lot of it just has to do with the balance of blood flow to, to airflow. So when you're having anaphylaxis, all your blood vessels are dilating, including in your lungs.

And when that happens, you, you don't get very good match of the parts of your airways that are full of air and the parts of airways where blood is going. And that can lead to, you inability to get oxygen where it needs to go. And that can lead to badness. So there's a lot of overlap and a lot lot of the inflammation that underlies asthma is very similar to people who have food allergies, because when you zoom out, all allergic disease is related in some way.

And the term we use for this in the allergy world is the atopic march. Kind of an old term, but it essentially an age-specific prevalence of allergic disease. So in infants and young children, we expect to see eczema first. That's usually the first thing

0:20:43 Thomas: Yeah. Yeah. To be calm. Yeah.

0:21:50 Thomas: Yeah,

0:21:50 Steve: That manifests.

0:21:50 Thomas: No kidding.

0:21:51 Steve: And then you move on to things like food allergy and then asthma and potentially allergic rhinitis. So people, if you live long enough, you'll get allergic rhinitus of some flavor, but they tend to follow an order.

0:22:03 Thomas: What is that part? What is the?

0:22:05 Steve: Is just seasonal allergies, environmental allergies. So just have to use fancy words for everything. So it's called rhinitis because it's inflammation of your nose. Yes.

0:22:07 Thomas: Oh, OK. OK. Huh.

0:22:11 Lydia: Runny nose.

0:22:16 Steve: That's why they pay me the big bucks, Thomas. But they're all kind of related in the sense that the inflammation that is causing them is very similar. And sort of brings me to one of the major points that I wanted to get to today was how do we prevent food allergy? I think that we got a lot of insight into this around 2015 when the LEAP study was published. Stands for Learning Early About Peanut Allergy, and there's a long story behind it, but in essence, it was some UK researchers that noticed that Israeli children who lived in the UK and ate UK food had way more peanut allergy than Israeli kids who lived in Israel and ate Israeli food.

And one of the things that they noticed was that in Israel, they have a lot of peanut based snacks, including Bamba. If you've ever seen this at Trader Joe's or wherever you can guys find it, it's basically peanut butter flavored Cheetos. They're a very popular snack. And, and were just curious, like, why if these kids who are not that much different, but they're eating slightly different foods, like why, why are they different in terms of their peanut allergy. What is it about being in the UK that makes peanut allergy so much more prevalent than in Israel? So they created the study where took a bunch of kids anywhere from eight to 11 months of age. So we're talking young who

0:22:18 Lydia: Yeah,

0:22:58 Thomas: Interesting.

0:23:35 Thomas: Yeah.

0:23:35 Steve: Are just getting into that range of being introduced to foods. Absolutely. You had to have eczema, basically moderate to severe your eczema and you had to have, uh, or egg allergy. So if you had an egg allergy and or moderate eczéma, you would be included in the study potentially. And they took half of them and they said, this half, you're going to avoid peanut completely. And not only did they tell them to avoid peanuts, they actually checked by vacuuming their bedsheets every so often and actually looking for peanut protein. Cause believe it or not, whenever we eat food, um, particles of it are on our clothing. It's

0:23:36 Thomas: Babies, basically. Sign our kids up.

0:23:43 Lydia: That's

0:24:11 Thomas: Yeah?

0:24:11 Steve: All over the place. It's in the floor. It's on our bed sheets.

0:24:12 Thomas: Hence

0:24:13 Lydia: So yeah, man.

0:24:14 Thomas: Hence why Arlo could have a hive at any given point, any time for anything. It's hard to know what that would be.

0:24:20 Steve: Lots of little pieces of food are kind of all over the place and so we can actually track this by, you know, vacuuming up your, your bed sheets and finding whether or not you are actually avoiding peanut or, or not.

0:24:29 Thomas: I was going to make a joke that like you could just, you know, wash those things. But then it's It's like, okay, you're vacuuming because you actually are tracking like what particles you're picking up.

0:24:33 Lydia: Right?

0:24:36 Steve: Yes, that, was part of the study to just make sure that it was clean in other words. So half of them are avoiding peanut. The other half are eating peanut at least three three times a week and they're eating at least two, tablespoons, I believe. So they followed these kids for basically five five five years. And they did food challenges to peanut in the beginning to make sure that you were not allergic to peanut and, you know, then told to eat a bunch of peanut. Cause that, that's not a great plan. Um, so but make sure the peanut allergic kids that, you Know, are truly allergic to peanut and then they're study.

0:24:37 Thomas: Okay, yeah. Gotcha.

0:24:56 Lydia: Yeah.

0:25:03 Thomas: I'm not just faking it.

0:25:05 Steve: Exactly. So Food challenges before, food challenges after. And what they found was the kids who were exposed to peanut three times a week for five years had about 80% less peanut allergy than the kids who were told to avoid it. A lot of the pediatrics, you know, food introduction practices before that were based on avoidance because there's a thought behind that, right? So the thought is it all comes down to the mechanism of allergy. Like it was thought, you know, you have to have been exposed to something first to then develop an allergy to it. So therefore, if we prevent you from seeing it at all, maybe we can prevent you From getting the allergy. And

0:25:05 Thomas: I'm

0:25:07 Lydia: Yeah yeah yeah

0:25:43 Steve: That was what drove a lot of the prior advice that we were giving to parents. Um, what we think actually happens is kids who who have eczema, your skin is a little bit leakier than it's supposed to be. So you're losing water. That's what makes it itchy and all of that stuff. But not only is water getting out, but food allergens are getting in. And So kids with eczoma who are crawling around on the food particle ridden floor with their eczematous skin are like smashing food proteins into their leaky skin every day as they're crawling around. And, their immune systems are thought to have basically seen the food through the skin first, and then that is how they developed sensitization to the food.

0:26:20 Steve: And then later when you eat the food and are already sensitized to it, then you can have the allergic reaction. So that's what we think happened. And again, we wouldn't know any of this stuff if Leap didn't do what it did. And it kind of changed our recommendations overnight in pediatrics

0:25:59 Thomas: Huh. Oh, and that's bad. Oh, okay. I thought you were...

0:26:37 Lydia: Yeah

0:26:37 Steve: About what we tell parents. It used to be like, avoid all the allergenic foods if you can. Now it's early and often basically is the recommendation. And

0:26:45 Thomas: Yeah. Hold on. You're saying the eczema, though, that part where they're rolling around absorbing the peanut dust, you said that makes it worse though, right?

0:26:54 Steve: It can.

0:26:56 Thomas: Okay. So then how did the... So if in this study, though, is it just that eating I guess I'm not I'm not totally understanding that connection there.

0:26:56 Steve: Yeah, it can, but a problem. So the difference probably lies, we think, in between the difference between seeing foods through your skin versus seeing foods through your gut. So those two surfaces are very different in terms of how they handle um, things that are supposed to be, uh, versus not foreign. Cause as you know, you're

0:27:13 Thomas: OK. Oh, so my teacher immune system kind of a different lesson depending on where you.

0:27:26 Steve: Yes, the, very petty. It doesn't like anyone. Right.

0:27:26 Thomas: OK. Yeah. Yeah. Well, that's fair. Yeah. We don't eat a lot of stuff through our skin usually. I mean, I do sometimes. But yeah.

0:27:31 Lydia: Super

0:27:34 Steve: Right. The goal is probably not to do that. And your skin is designed to keep stuff out. And so when stuff gets in, they get on edge. This Um, is a very, you know teleologic way of explaining the skin, but in essence, so,

0:27:38 Thomas: Oh, no, no. That makes that makes a lot. A lot of sense.

0:27:46 Lydia: Helpful. Yeah.

0:27:46 Thomas: Yeah. Yeah.

0:27:47 Steve: The thought is the skin is like a sensitizing surface. And so the gut is like the opposite because you're full of bacteria that are helping you. You've got lots of buddies that, you know, not,

0:27:55 Thomas: It's like, yum, yum. Yum. I want to be able to eat everything. We're just going to dumb it down as much as we possibly can. So then there's Mr. Gut and he's like. Yeah.

0:28:01 Lydia: Oh,

0:28:03 Steve: Not so much a clip -clop Tom, right. But close to it. Right. So, yeah. So we're going to contrast the gut with the skin, right? So the skin we think is a very sensitizing service. The gut, however, is a very tolerizing surface because it has to be because your gut doesn't work if it doesn't tolerate friendly bacteria and other things, helping you digest all of the that you're eating. So the with the LEAP study is after repeated exposure through the gut, you gradually learn to tolerate those foods. If you had only seen it through your skin and then you didn't eat it, you are not really learning to tolerate Those things. And therefore for your sort of cultivating an allergic response if you're avoiding foods.

0:28:06 Thomas: Yeah.

0:28:19 Thomas: This is mind blowing. So had thought that Arlo's eczema and when we talked about eczéma, I thought it was like, oh, it correlates with like the allergy and stuff. But like it could actually be causal, like it because he had a hell of a time with the eczema. Like he had a really rough time as a baby.

0:28:56 Lydia: So bad.

0:28:59 Steve: So, so a lot of people who have children with eczema will tell me, and this is true to a certain percentage of them, right? When they eat certain foods, their eczéma will flare. And what's parents will think, oh, the food is causing the eczéra, but it's actually kind of the opposite. So the eczema caused the food allergy, which then sort of reactivates the eczéma after you see the food again, because you have cells that are primed to see and recognize that food protein again. So when you eat it and it gets distributed throughout your body, those cells that in your skin react again, then you have kind of a flare.

And that happens in about 40 % of kids who have eczéra. Not every kid is going to have a food -relevant reaction. But that, that is the conversation I have almost daily with parents of kids with food allergies, where I'm trying to explain to them that the eczema is probably more of a causal mechanism than like the allergy itself. And I think it helps once we go through this process helps to understand like what's going on. And, and usually you don't start making progress on your food allergies until you've gotten good control of your eczéma. And I think that's a a general trend that seems to hold true. Obviously need more studies on that.

0:29:09 Lydia: Yep. Wow.

0:29:09 Thomas: Yeah. Yeah.

0:30:03 Thomas: So I was assuming it was like you were kind of, stuck. You I was just thinking like, oh, well, if Arlo, because he had his whole frickin' head was eczéma and he's probably got particles all in there and everything, he's just fucked in terms of allergies. But that not the case? I mean, he has so many I was imagining him doing this kind of study you were talking about, but he has so many allergies that it would be like, oh, his whole diet is now just two tablespoons of each allergy. Like, that would be his weekly freaking allotment of food.

0:30:22 Steve: Yeah. Yeah. It's tough when you have a lot of allergies. Now, that brings me to another point, and that is that not all food allergies are created equal. Like milk and egg are commonly outgrown by age five. Everyone, obviously. Everything's a bell curve, right? But when it comes to kids who have milk and eggs allergy, generally speaking, they're losing those things once they start school age. Is that? I don't know that we know. I think my best guess is that milk and egg are just such common foods that we end up getting exposed to them over time. And maybe why, I don't know.

Milk and eggs are treated very differently than nuts and shellfish and other things, because once you get those types of allergies, you're very very unlikely to naturally outgrow them. Like at most about 15 % of kids might be able to outgrow a peanut or a tree nut allergy. So depends on what you're allergic to. As you know, the number of foods you're allergic to, greater the it gets, the much harder it is to actually find a diet that feed can your child. You often have to talk to a dietician and and really work on kind of, okay, what is our plan to feed this baby so they can grow and get all the things that they need?

So I am often partnering with dieticians to help my patients who do have a lot of food allergies. So that is a very common topic that we talk about. The whole thing we were talking about here is how to prevent food allergy, right? So it's all about early introduction of lots of different allergenic foods. Now, if you're already allergic, by the time you start introducing those things,

0:30:41 Lydia: Yeah. Yeah,

0:31:11 Thomas: Okay. Oh,

0:31:55 Steve: Then that's different story. You do need to avoid it. What the LEAP trial suggests is that even kids who are highly at risk for developing food allergies, I .e. kids with bad eczema, they still see drastic reductions in development of food allergy if they're able to keep those things in their diet. And so it kind of flipped the script on what we told parents about how to to introduce foods. And I've noticed lately in the last few years that there've been a lot of products hitting the market related to early introduction of, of allergenic foods. So a whole new area, market that's being explored now. So you guys will probably see that stuff out in stores. So, okay.

0:31:56 Lydia: Yeah.

0:32:33 Lydia: You. Yeah, popped up, I think it was sponsor for a podcast or something, and and I don't remember the exact name of the company, but but it popped up and I asked our pediatrician about it, because when I was pregnant with Remy, I was like, you know, obviously high alert for food allergies, especially if it's going to be something different than what Arlo's allergic to, because my life would be even more of a nightmare trying to feed everybody.

0:32:50 Thomas: God. It would be the worst. Turns out Remy, though, it's fine. Don't worry. He's just allergic to not fucking screaming. Can't do it. Can't doing it at all. If anyone touches him with not screaming for five, he's incompatible. He has to scream at all times. It's a weird- have you researched that one? Tell me about that one, Dr. Steve? Can you fix that for me?

0:32:58 Steve: Uh,

0:33:03 Lydia: Oh, yeah, he can't he can'T handle it.

0:33:11 Steve: I I got nothing, man. I'm sorry. Yeah.

0:33:16 Lydia: Yeah. Try it. Try lactaid. But, you approached our pediatrician about it and said, like, hey, what do you think about this? And she's like, honestly, I feel like it's a lot of money to spend on something that you could just do yourself, but you're paying for convenience. And so for some people that makes sense. And she was like, but honestly, like I just think it's. A lot more money than you'd expect.

0:33:16 Steve: Yeah. Yeah, exactly. Yeah.

0:33:29 Thomas: Yeah, yeah, right. Well, Okay, how should we be thinking about Remy in light of all this? Remy's got a little bit of eczema, not know anywhere near as bad as as Arlo, but just kind of been starting- well, that's, I guess it's- it's been a little while he's been eating real food. How should we be consciously, and I'm sure Lydia, you're already doing this, but should we be consciously introducing all these allergens to him?

0:33:45 Lydia: Yeah.

0:33:57 Steve: You should be trying to introduce as much as you can. Um, know there are always limits to like how early is too early. I don't know that we know the answer to that question. Right. It's kind of like as soon as your child is developmentally able to start eating soft solids, you can start, you know, sprinkling in you PB2 powder into some of that stuff.

We'll get there to PB2 in a second, because what Lydia, what you said about, you seems like a lot to pay for something that you could just do yourself. That's an important guiding principle in my entire approach to peanut oral immunotherapy. Therapy. We'll get there, but what to introduce, the top nine food allergens. I think it matters which order, but they are milk, eggs, wheat, soy, peanuts, tree nuts, fish, shellfish, and sesame, the ones we know very well because you just went over that new law covering all of the labeling, right? But those are the types of foods that we should be gradually introducing into their diet as long as they can eat it. Obviously, we're not giving whole nuts to any child under two because that's a choking hazard,

0:34:44 Lydia: Right

0:34:58 Steve: Which

0:34:57 Lydia: Hazard yeah

0:34:58 Thomas: Right. I'm calling bullshit on the shellfish. If this, if this like idea is like, yeah, the eczema, then they're absorbing shellfish dust around a lot. Like, is there a lot of shellfish, you Know, like how are they getting that through their skin? They're They're, not thick skin.

0:35:13 Steve: Specific shellfish, you're probably Right in some ways, but remember that crustaceans all share lots of similar proteins and so, dude.

0:35:14 Thomas: Ooh. Ooh. So are there some bugs, some land bugs that are land bugs?

0:35:26 Lydia: Oh

0:35:25 Steve: Always land bugs. Um, there's always land bugs, so things like cockroaches. Um, those, those are everywhere. You don't really see them, but they end up in the dust that's everywhere, so they're more common in like public buildings where there's not people at night.

0:35:30 Thomas: Oh man.

0:35:31 Lydia: My god so gross right

0:35:41 Steve: But um, but in terms of, are they there? Absolutely they are. And um, it's not fun to think about because it is absolute nightmare fuel. But but you know, yeah.

0:35:41 Lydia: Yeah yeah

0:35:41 Thomas: Yeah. Yeah, wow. No, that is, that ist so honestly, I, I love this. I mean, I hate all I hate cockroaches. I hate all that, but I love that because it was like, here I thought this was like a pretty reasonable question, and then there's an perfectly reasonable scientific answer for it, which I love. That's my favorite thing, really cool, yeah.

0:36:03 Steve: So I can't promise you that every kid who develops a shellfish allergy is because of the cockroaches. But what I'm saying is that there's, there are things that are, that we're not really seeing that are affecting kind of how this all plays out. And yeah.

0:36:14 Thomas: So, presumably, if our diet, if we went to uh, Red Lobster and it was actually Red Cockroach, and we just have picture a different world where we actually eat bugs more like that, like they would probably have that allergy too. It's just that the only thing, the only way we see it usually, is because people like to eat shellfish and not cockroaches. Hmm.

0:36:21 Lydia: Yeah

0:36:21 Steve: Yeah. Yeah. And your, your point is exactly illustrated by comparing different cultures that that eat different amounts of seafood, right? So you go to Korea, Japan, they're eating way more seafood than we would ever dream of here in the States. And generally speaking, again, I speak for the Midwesterners among us. I love shellfish, but as a general regional diet, it's less common here than on the coasts or whatever, because easily available. But the allergens are the things that are commonly eaten, and it's mostly about opportunity for allergies to exist. And you you can develop an allergy at any point, right?

0:36:38 Thomas: Yeah. Yeah.

0:36:50 Lydia: Right

0:37:07 Thomas: It's kind of a double-edged sword, though. I was wondering about about that, because it's almost, it's both sides of the equation, right? Because it's, yes, it's more, you could, you, we're talking about this eczema kind of theory of it. Yeah. It's more exposure on that end, but also then it's just more exposure on the good end of, you're getting that early exposure to eating it. So it's, that's kind of interesting, though.

0:37:27 Steve: It's kind OF like you have to sort of remember like statistics and like winning the lottery, right? If you know, your individual odds are pretty low, but you know the more you, more tickets you buy, you know? Yeah, your, your odds could potentially increase. You hit the lottery AKA get a food allergy, like, you a rare event. But in aggregate as a population, as you increase the odds of everyone having a shot, a roll at the dice, so to speak, you're increasing the aggregate odds of having those types of reactions. And it's not just with foods. I mean, it's with medications too. There's a reason that the most commonly prescribed medications tend to be the ones that cause the most allergic reactions. Has to do just with opportunity. So your body does a pretty good good job at differentiating what it's supposed to react to and not. Sometimes it screws up and

0:37:30 Thomas: Sure. Right.

0:38:12 Thomas: Well, I, yeah. And maybe I'm thinking putting, too algebraically with this, But I just think of it in terms of, like, there's two sides of the equation there. If we know that that exposure could create the allergy, we also know that that exposure would be the cause of the disease. That exposure could mitigate the allergy. But in that study you referenced, it was still 80%. So, like even in the best circumstances, there could be an imbalance of, you It's creating more allergies than it's fixing, I guess.

0:38:33 Steve: On the whole, you know, exposure to these foods early is likely to develop tolerance and not sensitization. So that's what we want. We don't want it to develop the allergy and at least based, I mean, the LEAP study was incredible because you just don't see those kinds of results out of a clinical trial. I mean, it's like 80 % reduction in anything is like world changing when it comes to the practice of medicine. You know, we're working on the margins, trying to reduce things by five or 10%, you know, either way with a lot of effort. And this is something that everyone can do at home.

Assuming that every food follows the same pattern as peanut, which is assuming a lot, but I think at least in principle that it should work work with other foods, you know, we could do a lot to prevent food allergy in the first place. And this is not to blame people for not doing that if it does occur, because it's not like you could have, changed you the outcome per se, it's, but we're trying to get people used to this concept of early introduction is better. And I hear from a lot of parents like, well, yeah, we introduced peanut, like when they were six or seven months, and then they basically avoided it for years. And then we're surprised when their child had an allergy to it later. I we say introduce a food, you know, you do need to eat it regularly. So,

0:38:48 Thomas: Right.

0:39:18 Lydia: I

0:39:43 Thomas: You can't just be like, hello,

0:39:43 Steve: Yep,

0:39:44 Thomas: This is Mr. Peanut. Shake hands. It's nice to meet you. You've been introduced. Is you know they got a great plan here because they've got the turducken and I think we have an opportunity to create a food that's all nine allergens, yeah, like some sort of peanut flour, shellfish, something, egg, but yeah, but it wouldn't have to be like too big because we don't need much of it, right? So maybe just a little you know, yeah, a little, little, little, tiny, like a, like, like an hors d'oeuvre, you know, like a little bit.

0:39:48 Lydia: Did one sounds disgusting yeah gross Gross. Like a supplement. Like, yeah. Yeah.

0:40:16 Thomas: It's got a little bit of all those. Yeah. A little bit of all nine of those things.

0:40:16 Lydia: A moose boosh.

0:40:01 Steve: Yes. Some genetic monstrosity, right? Yeah. Okay. Yeah. Just up your super allergen into a fine powder and sprinkle a little on every meal,

0:40:24 Lydia: Yeah, smoothies.

0:40:24 Steve: Right.

0:40:24 Thomas: Could work too, but I think this will, I think I want to find a, like a five -star chef, Michelin star chef to do this, to make a good, that has a little element of each of the allergens. And then you could have your, you know, young child try it, assuming there's no allergic reaction. Then you just, it sounds like you want to just keep feeding them that, that a lot, right?

0:40:40 Lydia: But here's the problem. So if there is an allergic reaction, then you have to backtrack and figure out which is the problem.

0:40:43 Thomas: Then you, then you, yeah, exactly. Then you got to figure out the combinations.

0:40:46 Lydia: I did see, Steve, that there was some follow up from that LEAP study where they looked at kids, you know, who avoided peanut after age five that were okay and it looked like it was a um, right, like that even if you avoided it after you were a certain age, you still maintained that tolerance to peanut, is that right? Okay.

0:40:52 Steve: -hmm. Mm -Hmm. Yep. Yes. That is, I believe, the LEAP -ON study that you're referencing there. But that was basically, yeah, go figure.

0:41:10 Thomas: Are they going to of keep with the fucking acronyms forever? There's gonna be there's the LEAP jump study, now the jump to 21 Jump Street LEAP study, that let's just keep going with it.

0:41:12 Steve: Yes, yes, they are. Yeah. The acronyms are getting ridiculous. But yes, the seems to be persistent in that study population. And really, I think there's a lot of good research questions still being investigated. What is it about the, most allergists who who read this stuff believe that there is some sort of immunologic window when you're very young that sort of sets the tone for developing food allergies. And some of the newer trials that are being started now involve using not only things like oral immunotherapy for treating food allergic kids, but we're combining that with some ofthe newer biologic treatments that we can use for allergic disease. And I haven't introduced those yet, but these are things like Dupilumab or or Dupixent, and things like Omolizumab, which is Zolaire. Both of those are antibodies that we have to inject into patients, but they specifically target different parts of the immune system. And they need to be tested because we have a lot of reasons to think that would improve any effect that we're already seeing with things like oral immunotherapy. And because I keep talking about oral immunotheraphy now, and I realized I haven't introduce that.

0:41:31 Lydia: Yeah.

0:42:30 Thomas: Sure

0:42:30 Steve: I do think we should talk about that because the next big thing that I really wanted to talk about on this episode was, you know, what are the treatments for food allergy? Can we cure it? What do we do? So one of the major treatments to roll out recently was called oral immunotherapy, or OIT. And the concept is not too dissimilar from allergy shots in the sense that you're ramping up on how much allergen you're giving and you gradually do it over time to an increased amount.

0:42:30 Lydia: Let's get into that, yeah. Yeah.

0:42:55 Thomas: Same way I built my resistance to iocane powder, basically, that. Hmm.

0:43:05 Steve: Nice. So yeah, it's just through the gut instead of being injected. And this process, you Been tested quite a bit and there is now a, at least for peanuts, a peanut allergy, you Know, I hate to call it a medication because it's basically very very fancy refined peanut powder. It's called Palforzia and it was approved in January of 2020 back when there were some other things happening in world. Right. And I think probably its rollout was a little interrupted by the pandemic a bit because we had other things on our mind, but you, is basically a peanut oral immunotherapy product and you take a pill every day.

And so often you come in for an updosing where you go to the next dose of that pill and you gradually increase to about, I to say, 300 milligrams is their end goal. And put it in perspective, a single peanut is about 300 milligrams of peanut protein. And, in a reminder to everyone, it really is the protein of the food that you're allergic to. So you're not really allergic to the fat product or the, you know, the oil product, you're usually not allergic to any sugars. It's really protein, what we're talking about here. So, when

0:43:36 Lydia: Right.

0:44:16 Steve: You go to the store and you look on the shelf by the peanut butter and you see PB2, that is more or less what's in Palforzia. Would sue me if they heard this podcast probably, but it's, it's very refined refined peanut powder basically. And it has FDA approval, which for lots of reasons from a physician's perspective is something that we However, because I trained at Cincinnati Children's, we had our whole peanut OIT program and we used PB2. And rather than 300 milligrams of peanut protein, which is about a single peanut, our maintenance goal dose was 2000 milligrams of of peanut protein. And that was about, you know, six to seven peanuts, depending on how big they are.

The process takes, you know, six to eight months to get from where you're not having any peanut at all to getting up to the maintenance dose. Couple of weeks, you're getting a higher dose. And we do that in the clinic to make sure that you're not reacting to the higher dose, but most of it is done by parents. You know, you're giving your child this thing at home, which we teach you how to do, but it's a little different than most procedures because we're just letting you do it at home. But we train you how to do it. We train you to measure each one. And there's a lot of guidelines for what you can or can't do because your threshold for having reactions moves quite a bit.

So if you have a cold, your thresholds for having anaphylaxis lowers quite a bit. You go for a jog, that will also lower your threshold because there is such a thing as you exercise dependent food allergy. So you can eat a bunch of shrimp and then be fine and then eat a punch of shrimp, and then go for a run and then have anaphylaxis. So that is an entity that exists out in the world that we sometimes see.

0:44:16 Thomas: Hmm

0:44:48 Lydia: Oh, wow. Yeah. Wow.

0:45:49 Steve: So we have to incorporate lots of these things into these protocols because we need our kids to be safe, but it's a, it's a very safe process. You know, a majority of the kids, um, really only experienced some mild abdominal discomfort, there are risks to it. And really talking about OIT with patients takes me an hour just to talk about the risks, the benefits, what's involved, all of that.

But Children's recently did a retrospective analysis of some of the first 100 kids to go through their peanut OIT program. The results were pretty interesting. And most made it to maintenance with only minor abdominal complaints. You read the studies on peanut OIT, the problem is that all of the protocols are slightly different. So what Cincinnati Children's is doing is not the same as what Mount Sinai is doing, for example. You have to really look at the protocols and kind of what makes them different.

It's exactly to apples when you're doing those meta -analyses. But yes, when you do oral immunotherapy, because I am giving you something you're allergic to every single day, there are going to be some days where you have reactions. So the rates of reactions, including anaphylaxis and including needing epinephrine, those are increased in kids who are doing oral immunotherapy. That's a risk.

That being said, in the first retrospective that Cincinnati Children's did, there was only one patient out of 81 patients to through the buildup phase that had epi epinephrine during the build up phase. So, you

0:47:16 Steve: The rates are pretty low for those types of severe reactions. They are possible though. So that's a risk that you have to be willing to take if you're doing it. And so like, what are the benefits, right? Why would I do OIT and do all this really intensive updosing, right. Well, the bottom line is once you get to maintenance, you're eating six to seven peanuts a day, at least using Cincinnati Children's protocol. After 12 months of doing that, we actually have you do a triple dose of your maintenance dose in a single day, like in a simple visit. So you'll do, um, 2000 milligrams three times, um, 20 minutes apart. And then we sort of watch you and basically everyone who's agreed to do that challenge, um. Passed that challenge. Effectively not not concentration of peanut protein, um, at least in that range that would cause a reaction. And so the benefit that you get out of it is your children can likely, you be exposed to a small amount of your allergen and not have any symptoms really. Um,

0:47:16 Thomas: But

0:47:21 Lydia: Right?

0:48:10 Thomas: You know, it's not like you start munching peanuts all day every day and you're fine. It's just like it's kind of mitigating the risk quite quite a bit but

0:48:14 Steve: Right.

0:48:15 Lydia: Yeah. It's coupled with avoidance, right? Within your diet.

0:48:18 Steve: Correct. You'd still want to avoid it. And yeah.

0:48:19 Lydia: Yeah, yeah,

0:48:21 Thomas: I mean, that makes a huge difference in terms of the parental stress, you know, and

0:48:25 Lydia: Yeah.

0:48:25 Steve: Absolutely. I mean, so I kind of get two kinds of patients who want to do oral immunotherapy. One are the parents infants who just found out they were allergic and they want to do everything possible to mitigate it. And then I have teenagers who they're about to go off to college and parents are freaking out about them now being in charge of all of their food when they may not have been before. And so I totally understand those motivations. And those are perfectly good reasons to seek out this treatment. The hard part about this treatment is that not every allergist is trained to how to do this. And I was lucky because Cincinnati Children's does this at a pretty large scale, and I was able to learn how to do it. And there would be days in clinic, like in one afternoon, we would be doing nine different OIT patients, all doing updosings. So basically like nine challenges in an afternoon, noon. And that was pretty standard.

0:49:15 Thomas: Then Just Have A team of people with epipens, like, like it's almost like a firing line, like, you know, they're just waiting for you to make a move. I see a single cough, I'm In your leg.

0:49:24 Steve: You know, I proposed an epinephrine blow gun, but it was denied by the safety committee. So yeah, But yeah, it worked surprisingly well. It kind how I practice in the sense that I view peanut allergy and OIT in a much different light than someone who's never been trained to do that and has been told to, you know, avoid everything thing forever. And not patient, not every family is good a candidate for this because you are doing lots of the work and you can't exactly be spacing out on too many things if you're going to do this. You have to be really attentive to detail and all of that. So the selection process is pretty rigorous just because we don't want people just oh yeah, I'll do that, you know, willy nilly and not really paying much attention to all the details. So, so it is very high intensity on, on part of the parent. Whole thing is, you I'm going to have to choose between Palforzia, which costs about $10,000 a year to do it. Or

0:49:30 Lydia: My God.

0:50:20 Steve: If I can go to the store and buy a canister of PB2 powder for like 10 bucks, you Know, which one am I going to do? Um, don't really like the idea of medicalizing food. Um, don'T think it's practical because none of us eat food, um, in that way necessarily. Um. I have a very skewed view of this obviously, because that's how I was trained is to use PB2.

0:50:40 Lydia: Yeah?

0:50:41 Steve: And to me, I, I don't necessarily see all the benefits of Palforzia. I think for allergists who were not trained in how to do this, Palforzia offers you a lot of safety net in terms of, you know, this is an FDA approved process. A lot of people have vetted this. I don't like about it is that it only goes up to 300 milligrams. And I think your maintenance dose probably does matter. Not that I think you need to be eating a hundred peanuts a day, but there's probably a difference at some of those levels. And we don't have enough, you Know, long-term studies to really vet all of that out yet. And that is what a lot of allergists who are researching are doing now. So they're trying to figure that out.

0:51:16 Lydia: Can you tell, a little bit about the difference between oral immunotherapy and then like something like the egg ladder, right? Is not something that's avoidance beyond, right, you're trying to introduce egg.

0:51:22 Steve: Yes.

0:51:26 Thomas: What's The egg Ladder.

0:51:29 Steve: Yep. So the egg ladder is, um, I mean, I don't know that there's one egg ladder, Like as a, as a trainee, there's lots of egg ladders. Lots but, of different allergist have developed their own version of this, but it's different forms of variably cooked egg uh food products so you start with something that is very well cooked, yes.

0:51:33 Lydia: No.

0:51:48 Thomas: It's Not just when I was a kid, I ate photos and everything, that's just Gaston doing and Then Roughly Oh, your kid becomes the size of a barge, I get it, yeah, dang.

0:51:52 Lydia: Yeah. Yeah.

0:51:53 Steve: Exactly, oh man, flashbacks, okay. Um. Exactly, so we don't start with raw eggs, that's a bad idea. Um.

0:52:04 Lydia: That's a terrible idea.

0:52:05 Steve: You know, there's something about baked foods that for some allergens baking it actually degrades the allergen, um, in Other foods it makes it more allergenic, so you have to be careful. So, so like for peanuts, they actually become more allergenic when they are cooked.

0:52:12 Lydia: Right.

0:52:19 Thomas: It, no more baked peanuts, all right, well

0:52:22 Steve: Well, it just has to do with where the protein is sitting. So for The egg ladder, you're working your way up from very baked things to less baked things. The thought being you're just gradually introducing those things. And we have not yet come to a very clear decision on that in the allergy community about whether egg ladder is the best. I had some teachers, mentors at Cincinnati Children's who did the egg ladder and others who did not. And some of them are just on the, well, just eat baked egg every day train. And I think I'm probably leading more towards that. But the other thing is there's also egg oral immunotherapy, and there's actually a lot of good data to suggest that doing egg oral immune therapy is probably a little bit faster at getting you to tolerance.

0:52:24 Thomas: So Wait, what would be the difference exactly with That but

0:53:07 Steve: So Rather than eating like a baked egg protein, with egg oral immunotherapy you're just going straight to the the egg protein that's that's unbaked, and you're just gradually increasing the dose Of it, like you Would for Peanut.

0:53:16 Thomas: Okay, yeah. So You're Just starting with like a smaller dose, yeah.

0:53:20 Steve: Yes, so the egg ladder is more like food types and you're Just eating a serving of each, you know, each day, and working your way up gradually over several weeks, whereas

0:53:23 Thomas: But But effectively, isn't that the same? I mean, because you mentioned the baking kind of mitigates changes, the protein.

0:53:32 Lydia: Degrades the protein.

0:53:33 Thomas: So it's just, it sounds like the same principle, but just a slightly different delivery.

0:53:33 Lydia: Yeah. But

0:53:34 Steve: Yes. One is more shifted to the left because you have baked it in some of them. Right. And, and are moving the curve a little quicker or slower. So, yeah, I mean, in essence, they're the same thing. Um, oral immunotherapy you're just you're getting the, the, don't want to say raw protein, but you're getting the unbaked protein straight into your gut, but you're just increasing the dose of it.

0:53:37 Thomas: Okay.

0:53:52 Lydia: Okay and if you can tolerate that then you know you're likely to be able to tolerate it in the baked form.

0:53:59 Steve: How you generally do it with oral immunotherapy is you go through the protocol till you get to maintenance, and then you usually decide after so many months of maintenance, sometimes it's a year, whether to do a certain challenge. For me, because of the natural history of egg allergy, with most kids outgrowing it by age five, it's kind of a moving target and and it's moving pretty quickly. So, um, can usually identify, you know, kids who will tolerate baked egg just based on looking at the allergens in, in the blood. Um, you make IGEs against egg, but we can get a little more specific and look at more specific proteins within egg that, that can then differentiate.

0:54:09 Lydia: -huh. Right. It's

0:54:33 Thomas: What's an IGE?

0:54:35 Steve: An immunoglobulin E it's an antibody that that leads to allergy reactions. So,

0:54:38 Lydia: When we do the blood tests for Arlo and it reports the IgE level right and the the likelihood of a reaction.

0:54:39 Steve: Yep.

0:54:39 Thomas: Okay. Yeah. All of our listeners have done that with Arlo. So I'm just making sure that, yeah, listeners are following.

0:54:47 Lydia: Yeah that's fair. Well

0:54:51 Steve: IgE blood levels is one way that we track over time, kind of how you're doing with your allergy. That's generally an indicator of what direction you're going in. It is not like a one -for -one clinical correlate. So I can still have people with very low IgE levels have very severe reactions. I can also have people with relatively high IgE levels and tolerate a food challenge. So that's part of the challenge with, with allergy is that our testing is not the best in terms of, I can't have you walk into my clinic and tell you just within a few hours, like exactly your, your odds of, of having an actual reaction to the food, unless I do a food change. And that is one of the things that a of the studies have to incorporate because

0:55:18 Lydia: And see

0:55:14 Thomas: Huh. Really? Really? Not like the Metachlorian system, which is, which is flawless and perfectly predicts how much of the force you have. Okay.

0:55:38 Steve: Right. Yeah. I wish we had it as figured out as they did in the prequel series. Yeah, it's frustrating because it sort of just gives me a yes or no answer as to could you be sensitized to this allergen? And we can create bell curves by using populations of kids who are allergic to things. But at the end of the day, your individual child has their own nuances and I'm not always able to predict exactly what will happen. And that's why the gold standard for food allergy is a food challenge. You know, I sit you in my clinic and we gradually feed you increasing doses of the food in question and

0:55:42 Thomas: The prequels.

0:56:13 Lydia: What

0:56:13 Steve: We see what happens.

0:56:13 Lydia: Happens. Yeah.

0:56:14 Steve: And I wish that science could give us better than that, but at least right now that's what we've got and working on it, but it's a work in progress. Us, those are things that we can check for. So when I look at specific proteins and I can find the IgE levels to those specific proteins, sometimes that clues me in to someone who can tolerate a certain type of food. So for egg, there's only really two.

And that is something that I always look for in my egg allergic kids is to figure out, okay, are we going to start with a baked egg challenge first? And that's usually where I start with any sort of challenge in someone who I'm worried about having an egg allergy and seemed to test positive um in the blood work, but also skin prick testing, which is the other thing that we do, which is we scratch the skin slightly with the little plastic toothpicks and um wait for it to create a hive basically. So can we hear food allergy, you know, we talked about OIT, gradually increasing doses of the food in various forms. One way, it's not a total cure. You're for a period. If you're on OIT and you stop taking your daily dose, you then lower your threshold of having a reaction again, and you may still have reactions.

0:56:59 Thomas: Yeah. Really?

0:57:23 Steve: So it is a treatment that is for life.

0:57:24 Thomas: So it's like you, you constantly forever have to take like one peanut at breakfast or whatever.

0:57:30 Steve: As far as we know, yes, because we don't have studies going out far enough to really tell us long -term outcomes, but Sounds Sounds

0:57:35 Thomas: I'm I'm just imagining my pill organizer, but there's a peanut in each day. Did I take my peanut today? Oh yeah, I did. Okay.

0:57:40 Steve: Delicious. So that's OIT. There is this treatment, which everything with TIP is going to be in air quotes, but TIP stands for Tolerance Induction Program. It is basically one person's project, and that's Dr. Randhawa. Um, don't know exactly what TIP is other than he uses lots of labs and does lots of hand-waving about machine learning and endotyping food allergy folks Into Groups.

0:58:11 Lydia: Talk a lot about AI. Yeah? Yeah.

0:58:14 Thomas: The context for this?

0:58:15 Lydia: So essentially, you navigating Arlo's allergies, you provider was, you know, saying just strict avoidance. That's option you have. Oral immunotherapy has been popping up in some of my searches. And then another thing popped up in my searches, you know, like desperately looking for, like, what can I do for my kid to, you know, make this a little more manageable in life for him. And the Food Allergy Institute down in Southern California kept popping up. So I looked into that a little bit. And it seems really interesting. You know, when I'm looking at their website and I'm look at their success stories and everything, it seems like sort of that beacon of hope as a parent of a kid with food allergies. And issue is it exists, you you said, Steve, it exists within this one particular doctor's mind.

0:59:04 Thomas: Huh?

0:59:04 Lydia: And there's really nothing that is publicly available about what they're doing. Um.

0:59:10 Thomas: About like, are there, there results publicly available in any formalized way that a bunch of good Yelp reviews.

0:59:15 Lydia: So, I mean, from what I've seen, they do post Like Yeah, it is a lot of good Yelp reviews. Um, goal, they're, of their program is that you are desensitized enough that you are, like, free, you're, you, not allergen-free necessarily, but your body can tolerate it, you still should have an EpiPen, you, if you do react, but you should be able to to eat whatever you want. So, again, as a parent with a kid with food allergies, yeah, it's like, oh, my God, like, where do I sign up? And then like you see the price and you're like, I'll pay whatever. You know, it's something that you really, really want to do. They have people flying in from Dubai, from the UK.

0:59:40 Thomas: Sounds Like A miracle Yeah Yeah Not Peanuts, let me tell you, the price, in terms of the price

0:59:56 Lydia: And, you know, and it's a significant investment of money, of time, of resources. You're staying in Long Beach for extended periods of time to do all these labs. And so my question is, like, is this thing real? You know, before I write a check for, you know, thousands and thousands of dollars.

1:00:12 Thomas: Yeah Before we book an Uber for our loan, just Send them down

1:00:16 Lydia: Yeah. Yeah, then, like what what actually is this thing? Is is this the future? What do we know about it? And so Steve's looked into that a bit.

1:00:16 Thomas: Oh I love it. Hmm.

1:00:24 Steve: We Don't, we, Don't know much. So there's, uh, there's two published papers if you want to call it that. One published in 2019, and it basically just shows 51 patients from their cohort that they just compared before and after treatment, and did not do any – well, they didn't do a lot of things. I'll just put it that way. Um, did not confirm the food allergy through food challenges, which is a kind of a standard for most publications involving food allergy treatment. Now, not every one has that. So, it's possible to do a food allergy study without doing this, but if you're talking about a clinical protocol, you basically need to be showing that it's, real. First of all, that you're actually treating what, what you say you're treating meaning.

1:01:06 Thomas: I Say, though, that the odds that it wasn't real, but someone paid a billion dollars to send their kid there, seem low, right?

1:01:13 Steve: So this whole thing with the Tolerance Induction Program just screams scam, um. Absolutely. Um, they told us what they're doing, exactly, they, they, one study this year about, from April 2023, and plus one, um, Rendala was the first author, it's basically telling us about some of their machine learning design, but I can tell you, after reading it, that I didn't really, I was not able to Connect this With their Protocol Well

1:01:19 Thomas: Yeah What Are They Machine Learning, like, what is, are They making a medicine that does something, uh

1:01:46 Steve: They're Getting lots and lots of different labs from the patients who join this program, and they're trying to create data from it that they can mine and then try to sort people into endotypes, which, which they don't explain, don't say what those mean. They did not compare this protocol to other OIT protocols. The major difference that I can see from reading it is that their program shoots for once weekly dosing, whereas most oral immunotherapy programs are daily dosing. Than that, though, they, you know, they didn't confirm peanut allergy with a food challenge, challenge, really, in this one paper from 2019 that showed all the markers, they that showed they had improvement in allergy markers, but any OIT program can show you that, didn't see from this paper what made their program really different. And I think that's one of the criticisms that a lot of allergists have levied against this particular program, because it's just in the dark and anything that's sort of a cash only operation and there's not a lot of info behind it and it sounds too good to be true and their owner is disrupting the allergy industry and They Use

1:02:58 Steve: Phrasing Like That.

1:02:57 Thomas: If If There's The word Disruptor In any of the website, I'm not sending Arlo, not doing it Yeah.

1:03:01 Steve: Yes. Yeah. And so look, I give anyone the benefit of the doubt, but you have to show me the data. Like my old mentor used to say, you know, all things are possible without data. Right. So, um, believe it when I see it. And so there wasn't much to go off of, and I don't want to do a journal review after the end of an hour of me rambling on about allergies, but I will say that there's not much in here that strikes me with any degree of confidence in terms of, I don'T even know what they're doing. I know.

1:03:13 Thomas: That Is bizarre Well

1:03:15 Lydia: Right I

1:03:32 Steve: I'm sorry. It's A buzz Kill It's

1:03:30 Thomas: That's Frustrating Yeah Yeah

1:03:32 Lydia: Know I was Really Bummed Has He

1:03:34 Thomas: No Good. Good to know. Very useful information there because I'm sure, look, who knows? Maybe it could be legitimate, but then just fucking demonstrate that for us. And we'll give you whatever billion dollars. If you give me the science, we will save up the money and send Arlo there. We would love to.

1:03:38 Steve: Uh Yeah I I Am Happy, yes I Am happy to believe it as soon as someone shows me anything that that is, like, convincing, show Me the data Um

1:03:54 Thomas: Yeah. Yeah.

1:03:56 Lydia: Been responsive to the community's calls for, like, you, if this is real, you, it kind of thing, or just Continues To operate His own, yeah, hmm

1:04:01 Thomas: Too busy cashing checks.

1:04:03 Steve: Don't think so, but it's hard because Look is running kind of a one-man allergy show at this place, um, he's hired a bunch Of more people I Don't know, but no, no, you don't want that.

1:04:05 Lydia: Oh

1:04:10 Thomas: Like, in general, in medical science, does that happen? Like, are there things where, you know? Okay. OK, I was trying to think like if it's niche, you know, like maybe there's not like one person. Yeah, I feel like that's not usually how it works, but I wasn't sure.

1:04:23 Steve: So, so just to put it in perspective, you know, when, when I came from Cincinnati children's to, to Western Michigan, you Know, at Cincinnati, I was one of about 15 attending allergists, you knows, seeing patients and doing research and, here to Western Michelin, I, I am the only allergist and those are very two different different ways of practicing medicine. You know, I, here I get to do everything. So, um, that's nice because I don't have to cater to anyone else's whims. I get To do the way that I want. Um, it, it is just one person, right? It's just me. And I'm not going to have this sprawling, um. Allergy Institute with just me, um think we just have to be cautious about any sort of clinical treatment, you food allergies still in the infancy where we're learning things.

1:04:41 Lydia: Wow. Mm. -hmm.

1:05:05 Thomas: Right. Just you, but you're administering what is the like accepted scientific kind of practice. It's not you're not doing wizardry that's of your own book of lore. But is there anything in medical Science where I don't know, maybe because it's so niche where it's something like that, but probably not. Right. Because you point out, I mean, you got to pay out of pocket for this. The insurance companies, I'm guessing, aren't like, "Yeah, we'll pay for this black box treatment that we know nothing about." Yeah.

1:05:13 Steve: Yes. Yeah, yeah.

1:05:14 Lydia: Robust.

1:05:32 Steve: Yeah, I mean, expertise obviously can be very niche and I don't mean to suggest that you can't get something like that, but you're not generally going to come up with a whole protocol from scratch on your own. Everything that I practice as an allergist was built on the shoulders of generations of scientists and physicians who who came before me and figured stuff out. And there are things we were figuring out, but a process. That's what science is about.

That's why we science, because it delivers the goods, right? You have to prove it. And that's how this thing works. You can't just go in there and pretend to be a wizard, like you say, and not let anyone behind the curtain and just hope for the best. And this not seem to be entirely transparent. And reading the two papers that they have out, it does not shed much light on any of that for me. They published in 2019, was 51 patients.

And in the retrospective that we did just on the first wave at Cincinnati Children's, we had slightly over 87 patients that we were doing an analysis on. I think it started out it as a hundred something, but in terms of who made it all the way through, you know, the maintenance dose, you know, 51 patients is not a lot. And for as many patients as he's claiming to treat, like 8,000, I would like to see a little bit more data on that.

1:06:49 Steve: So, yeah.

1:06:49 Thomas: I'm sure you could have used any of those to like get more data right

1:06:50 Lydia: Sample size yeah yeah yeah

1:06:54 Steve: So and again, it's like, do you, I I still put the onus on you, Dr. Randhawa to show the data, like, I know that you're just one person, but you can't be making the claims without supporting it. So he seems to to be doing the front loading of all the claims. And, you not seeing the yet. So be wary, just like you should be of anything if you're a critically thinking, scientifically minded person. So allergy is no different than anything else. So

1:07:01 Thomas: Yeah yeah yeah all right. Well, that's all the time we have and plus some, but thank you so much, Dr. Steve Propper. Really fascinating.

1:07:23 Lydia: It was so fun.

1:07:28 Thomas: Also, I mean, is there anything, we always give people the opportunity to plug anything. I mean is there, is that something that you want to talk about? Anything you'd like to point people to talk

1:07:27 Steve: Thanks, guys. So all I will say is if you have a child with food allergy, make sure you talk to an allergist and please visit a lot of the organizations that support those kids and their families. Those are things like FAIR, which is the Food Allergy Research and Education Organization. Organize lots of things, lots of advocacy, and they are definitely good partners to have as a practicing physician. I don't have any personal projects rolling right now. I'm just uh, you know, doing my thing in the clinic and

1:07:56 Lydia: Except for

1:08:01 Thomas: To Excellent. Thank Yeah. You so much. Really appreciate it.

1:08:05 Steve: Guys. It was a blast to be on and great to talk to you.

1:08:06 Lydia: Yeah, thank you.

1:08:25 Steve: Always land bugs um