Happy Sunday, y'all.
Elise Hugh here.
Today we are bringing you a Sunday pick where we share an episode of another podcast from TED, handpicked by us for you.
For many of us around the world, it's that time of year for allergies.
This raises some interesting questions like does eating local honey help reduce allergies through micro exposure to pollen?
How effective are at-home allergy tests?
And why do so many Olympic athletes have asthma?
In today's episode of TED Health, host Shoshana Ungerleider sits down with immunologist Dr Zachary Rubin to dig into these questions and more.
From cat dander to pollen to peanuts, Dr Rubin discusses how minor to severe allergies can affect your health and what you can do to manage them.
Listen to TED Health wherever you get your podcasts.
Learn all about TED's podcasts at podcasts.ted.com.
This is Ted Health, a podcast from Ted, and I'm your host, Dr. Shoshana Ungerleider.
I have to make a confession to you.
I was not the biggest fan of the subject of immunology in medical school.
Immunology is what it sounds like, the study of the immune system.
But when I was in school, it felt like trying to memorize a language that I didn't speak.
Antibodies, IgE, mast cells, histamine.
I learned to recite the terms, but honestly, it all felt pretty abstract.
Allergies especially were taught as these isolated moments.
A kid sneezing in the spring, someone breaking out in hives after eating shrimp.
It felt like an allergic reaction only had a beginning, a middle, and an end.
No root cause, no underlying meaning.
Why does the body suddenly decide that grass is the enemy?
How can something as small as a peanut in a Snickers bar become a life or death threat?
Back then, we didn't spend much time on these deeper questions.
But over the last decade or so, the whole field has shifted.
We now understand allergies as part of a much bigger story about how the immune system learns, adapts and sometimes gets a little too good at protecting us.
The thinking has moved from just avoid the thing that you're allergic to toward treatments that help the immune system slowly unlearn those reactions.
When the pandemic happened, these conversations went into overdrive.
Suddenly, everyone was talking about immunity, what it actually means, how vaccines work, why some people respond differently than others.
The immune system was no longer a niche topic in medicine.
It became a dinner table conversation.
And yet, for many of us, including doctors, it can still be hard to keep up.
The science moves quickly.
The noise online moves even faster.
So I find myself paying attention to the people who can cut through that confusion.
The ones who can explain complicated science in a way that still feels human.
And one of those people is Dr. Zachary Rubin.
He's a double board certified pediatrician and allergist immunologist practicing in Chicago.
He's also a nationally recognized public health advocate, a trusted media voice and the author of a New York Times bestselling book called All About Allergies.
With more than 3 million followers on social media, Dr Rubin has become one of the most accessible translators of complex immunology into practical and everyday guidance.
I am a generalist physician.
I don't treat allergies all day every day.
But I get questions about them all the time.
From my patients, from friends, from my own family.
And more often than not, I catch myself thinking, I wonder what Dr. Rubin would say.
So yes, I'm professionally interested in this conversation, but I'm also genuinely excited about it.
So stick around for this interview after a quick break to hear from our sponsors.
Dr. Zachary Rubin, welcome to TED Health.
Thank you so much for having me.
It's really great to finally talk virtually face-to-face.
Yeah, likewise.
So I want to start simple here.
When someone says I have bad allergies, which is actually me right now what does that actually mean?
Like what's happening in the body when someone reacts to pollen or food or a bee sting?
Right.
So there is an immune system response that's quite complicated.
I'm going to distill it down to the basics.
So at some point, your immune system looks at something like pollen and thinks it's basically a parasite and starts making these proteins called antibodies, specifically known as IgE.
If you ever get a blood test, that's what they're measuring.
And that's a process called sensitization.
So you make those antibodies, they sit around your body and eventually you get exposed to that substance again.
And that's when your immune system becomes active.
And there's two phases.
There's an early phase where histamine and some other chemicals are released that can create some relatively minor symptoms for some people, more severe for others.
It could be sneezing, itching or runny nose.
But then you start having this late phase reaction where cells called eosinophils and some other chemical messengers come in and create inflammation.
And that's where you start getting more congestion.
Post-nasal drip potentially a lot more coughing involved.
And that's a little bit harder to reverse that process once that starts to set in.
And so if it's for environmental allergens like cat dander, pollen.
It's going to create some of those upper respiratory symptoms, maybe a rash like hives.
And then for food, it could actually be potentially life-threatening.
We call that anaphylaxis.
Okay, okay.
I love starting here because I think it gives us sort of a shared language.
And once we understand what's actually happening inside, everything else about allergy starts to make a lot more sense.
And so, building on that, Allergies are often treated like maybe minor annoyances for some, but for some people, of course, they're life altering.
So can you share a story, maybe from your clinic or your training, that shows what's really at stake here?
Yeah, absolutely.
And so I'm going to paint a general picture of what I see, rather than one particular story, because I see this almost every day.
So oftentimes, whether it's a child or an adult who have severe allergies, they end up having a little bit of a harder time at work or at school because they're not able to sleep as well.
Because once you have that significant congestion, you're mouth breathing a lot.
So that could dry out your mouth.
You're not getting the same Air quality coming in through your mouth is your nose.
You may be waking up in the middle of the night because you're itching and sneezing and having a hard time breathing.
So you're just not sleeping as well.
We know sleep is one of the most important aspects of your health.
If you have poor sleep quality, you're at higher risk of developing obesity, high blood pressure, even diabetes.
And in the short term, it's functioning at work and at school.
And it's so bad that in Japan it's considered a national public health crisis, to the point that many companies will pay their employees to move away during their spring pollen season and temporarily live in other parts of the country, or they even go to places like Hawaii or Guam to work temporarily to get away from their pollen season, because they lose up to about a billion dollars a day in productivity because allergies are so bad there and it's taken very seriously as a national health issue, which we don't see that as much in the united states.
Treated it the same way.
It's often the butt of jokes, are not taken as seriously, but many people have a hard time with their quality of life or they end up having higher risk of ear infections or sinus infections and needing antibiotics.
So It's not just something to sneeze at.
This is something that we really do need to take seriously to make sure that people are as healthy as possible.
Oh, my goodness.
Absolutely.
And I would just like to say I'd love to go to Hawaii for the next couple of months to get away from my allergies.
Take a sabbatical, yeah.
Yeah.
So I think hearing those real-world stakes really...
And it also makes me think about how people emotionally process that experience.
And so I think you've said our immune systems are learning systems.
And I love that framing.
So how do you help patients understand that allergies are not a flaw but more like a miscommunication in the immune system?
Right.
So a lot of times you see in the media and pop culture.
You know SNL is an example where people living with allergies are seen as weak or that they're a loser, a geek.
It's this stereotype that needs to go away, because even the most elite athletes can have asthma and allergies.
In fact, it's roughly about 10 to 15% of Olympic athletes have asthma, as an example.
And so it's not that they're weak.
Clearly, they're the best athletes in the world.
It's that their immune system is abnormally responding to foreign substances and thinks that these substances are a lot more dangerous than they actually are.
As an example, when we talk about asthma, your airway has to determine if whatever's coming inside your lungs is safe to be around or not, and you can have an exaggerated immune response where you get more inflammation, more mucus plugging up the airways.
Anybody who breathes in wildfire smoke is going to cough because that's a lot of material at once.
But little bits here and there, generally don't cause the same types of severe symptoms if you don't have asthma compared to if you do.
And so it's that exaggerated response where the immune system is almost too hyperactive for its own good.
And so when you hear people say hey, take the supplement to boost your immune system, in reality that term doesn't make sense.
Because if you're boosting the immune system, you're actually increasing the risk of developing not only allergies but autoimmune disease as well, because that's a similar type of reaction not to the foreign substances but to your own healthy tissue, like you see with lupus or thyroid disease as an example.
Yeah, that framing to me actually feels incredibly hopeful, meaning that this isn't a broken system, it's just a confused one maybe, which I hopefully naturally leads me to the next question that people always wonder is it ever possible to actually get rid of allergies, to correct that miscommunication in the immune system?
When it comes to environmental allergies, there is a way to what we call desensitize the immune system, and it is kind of training it to be less reactive over time.
So we do that in the form of shots or drops.
Shots are a little bit more effective where we take what you're allergic to in small quantities and slowly increase the amount that you're exposed to through injection to introduce that reaction foreign substance closer to your lymph nodes of your immune system rather than inhaling it.
Or it's on your skin which your immune system is not the same throughout your body.
So when we do it in that controlled way, It's essentially like taking your immune system to school and showing it the same thing over and over again and boring it to death.
Okay, fine, I've seen this for a hundred times.
It's not that big of a deal.
I'm not going to send out all these chemical messengers like I did before.
And it's not technically a cure, because if you stop it it theoretically can revert back to what it was before.
That's why the term is desensitization.
But it is the only disease-modifying treatment that we have where we're actually really fixing the root cause of it, rather than saying okay, avoid exposure, take medications for the chemicals that are being released.
Those are more like Band-Aids, but immunotherapy the shots or drops is a way to really get at that root issue.
There are now dozens of at-home allergy tests that you can order online a cheek swab, mail-in kit and then suddenly, maybe you're told you're allergic to 50 foods.
For someone who's curious about their triggers.
What's useful about these tests and where do they fall short?
The usefulness comes into play when there's little access to seeing a specialist.
So in some places, depending on where you live, it could take six to 12 months to see somebody, if at all.
In other places, like where I live in the western suburbs of Chicago, there's a lot of allergists so it's a lot easier to get in.
And so that can be a limited resource where an at-home test may make sense, but for the vast majority of situations it actually falls quite short.
And the reason being is one you could have a test where they claim they're gonna help you and it really doesn't.
As an example, food sensitivity testing.
It's not measuring for anything that's gonna change management.
Versus a food allergy test, where we're measuring the IgE antibodies that I mentioned earlier, There's a high false positive rate, meaning it'll say you're allergic because it's positive, but in reality you're not.
So people may order a test that's several hundreds of dollars and told you should avoid 20 foods, when in reality, if you're eating them and not reacting, you're not allergic.
The clinical history is much more important than any testing when it comes to these issues.
So we have to combine the clinical history of what's going on and determine will these tests help us confirm that diagnosis, to then act upon it, rather than just trying to look for a needle in a haystack.
Because if you do it that way, you're likely going to poke yourself and hurt yourself along the way.
And I think because it's so easy to get overwhelmed or even misled when you're just trying to feel better, that really ties into the bigger issue of how we evaluate health information in general.
And of course, you spend a lot of time addressing health misinformation online.
And when you see a natural antihistamines, immune boosting supplements.
What questions do you wish people might ask before deciding whether there's any truth to it?
Right.
So I always encourage people to have a healthy dose of skepticism when they hear bold claims online, especially if they're giving a confident, simplified explanation to a complex problem.
So when people see a viral claim online, especially when it comes to supplements or various treatments, you got to ask OK, has it been tested?
How has it been tested?
What is the actual outcome that they're measuring?
And has it been reproduced in populations that apply to me?
You can make a viral claim about something and it only applies to a very small subset of a population.
But is that generalizable to the entire country or to all adults or all kids?
Generally speaking, most of the time it's not, unless you look at the evidence-based guidelines that are put out by various medical societies.
Most of the time, these claims only apply to a small group, if at all.
It feels like we're all trying to navigate this flood of advice all the time.
And sometimes even for doctors, it's hard to know what's harmless versus what's actually unhelpful or even risky.
And you've got a huge footprint online.
So you know that social media is full of allergy advice.
It's cut out dairy.
It's cut out gluten, eat local honey, take massive doses of vitamins.
What are some of the most common allergy myths that you hear, and which ones do you wish would just disappear?
The number one is often local honey treating allergies because it may seem harmless on the surface, but the reality is that when people are struggling to treat their allergies, it's better to get that specialist advice and care.
And I'll see you next time.
Local honey, it's great to support local businesses.
It can be a tasty treat.
It's known to help with a sore throat and a cough, but it's false advertising to say that it's going to treat allergies by acting like allergy shots, because the pollen that's in local honey is not what you're actually allergic to.
You're allergic to pollen from wind-pollinated plants and honey, and the pollen that's there is not ones that you're exposed to regularly.
So that really needs to go away.
Other myths that I see online include there's a type of meat allergy called alpha-gal syndrome, which is now probably the 10th most common food allergen in the United States, because when people are bitten by certain ticks –.
In their saliva there's a sugar molecule called alpha-gal that when they're bitten, you then become sensitized to the sugar molecule.
That's found in all mammals except for humans and certain primates.
So if you eat beef... pork, venison, dairy products, certain medications.
It has that sugar molecule and it can create a potentially life-threatening allergic reaction.
And so there is a treatment called SAT, where they take needles and acupuncture and put it in your ear for several days or if not weeks, and they claim it cures alpha-gal syndrome.
And that is something that can cost a lot of money that is not shown to be helpful.
And, if it was helpful, this would be a cure for food allergy in general, because it's the same type of immune response.
So it really doesn't make any sense, but it gets advertised quite a lot lately on social media.
So I have never heard of alpha-gal syndrome.
How does one know if they have it?
Let me just give you a brief history about this.
So especially in the East Coast where this first kind of originated, there were many people who would complain of having hives or problems breathing at night for no reason.
And it looked like anaphylaxis.
It looked like a severe allergic reaction.
And Doctors were just puzzled by this.
They call it idiopathic anaphylaxis because they didn't know what the underlying cause was.
And then they really thought hard about what was happening with these patients who were waking up in the middle of the night with these symptoms.
And they did a lot of history taking and a lot of studies to figure out that, oh man, these people who were waking up in the middle of the night were also having these antibodies to the same sugar molecule.
And oh, these ticks called the Lone Star tick were endemic to those regions.
These people were getting tick bites and becoming sensitized to this sugar molecule found in meat.
It almost looks like food poisoning after having steak.
And it doesn't always happen.
It's an inconsistent allergic reaction that sometimes it'll happen and sometimes it won't.
And it's often delayed by four to six hours after ingestion, which is not like a classic food allergy, that's more immediate.
So you really have to have a high index of suspicion to know if this exists.
And so I've made content over the years trying to raise awareness to this, because many people in healthcare don't even know that this exists.
Okay, fascinating.
Well, thank you for educating me because I am a doctor and have never heard of this.
More of my conversation with Dr. Zachary Rubin after this quick break.
It makes me curious, hearing all of this, to know a little bit about your own journey into this world of social media.
You've built a huge following explaining all sorts of things about science, including allergies, on social media.
Did you ever imagine yourself doing that?
And what made you realize that there was such a big need for clear explanations about allergies and immunity?
For A lot of people who got into this space, this happened because of the pandemic.
So I had finished my fellowship at WashU in St.
Louis right as the pandemic was starting.
And I had moved to the Chicagoland area to join a small private practice, as everything was shut down.
So it was very hard for me to connect with people when there were no social events.
And as a specialist, you need to connect with primary care to get referrals.
And so I went on social media just to connect with people.
I really wasn't on it before.
And I was on Twitter and I quickly realized oh my God, there's so much bad information on the Internet.
And this is what people are actively seeing.
I, even early on in my career, saw somebody who brought their kid in and said they were using a nasal spray with iodine in it because they heard about it on TikTok.
And that's not something we generally recommend.
It could be potentially harmful.
And so I was starting to see the effects of the misinformation, whether it was the COVID-19 or allergic diseases.
And so, spring of 2021, A medical student from Canada asked me to go on TikTok to make videos, and at that time I thought why would I go on a children's dancing app?
I didn't really understand the power of it at the time.
Obviously, hindsight's 20-20, but I said, okay, I'll give it a try.
Slowly but surely, I started making a ton of connections, building a following.
I joined Team Halo, 5Ds for the World Health Organization.
And I know you and I connected through that and met a lot of wonderful people.
And it just morphed into what it is now over the years, to the point that I have over 4 million people following me on multiple platforms online.
I had a book come out recently called All About Allergies that made the New York Times bestseller list talking about allergic diseases.
Congratulations, by the way.
Thank you.
It's provided so much more that I love what I do in the clinic and I also love what I do online, because they intersect so much that I'm helping bridge the gap between doctors and patients and building trust back by giving that nuance and clarity that is so desperately needed online.
Yeah.
And clearly that clarity is filling a gap.
And it's literally saving lives in some cases, especially when we talk about emergency situations.
And so I want to talk about epinephrine.
Okay, it saves lives, but many people don't carry it if they need it or hesitate to use it.
What are the biggest myths you hear about EpiPens?
A lot of folks are very scared of using it, thinking that if I use this, that means I'm going to die.
The connotation associated with it can be quite scary for people, or I have to go to the emergency room if I use it.
And so I want to tell folks that the recent evidence-based guidelines from our American Academy of Allergy, Asthma and Immunology say you need to talk with your doctor about – how to treat anaphylaxis and whether or not, based on the symptoms, it's appropriate to go to the emergency room or not, based on individual situations.
So this is something that we're starting to move in a different direction of shared clinical decision making, instead of just blindly going to the emergency room every time you use it.
Many people think that you go to the emergency room because of the epinephrine itself.
It's not that.
It's the fact that we're treating a severe allergic reaction and sometimes you need multiple doses, or you may need other medications, or you may even have a secondary reaction several hours later.
We call that biphasic anaphylaxis.
So, understanding why you go there or if you need to go, there is an important discussion to have with your doctor and have a written action plan to know.
Okay, based on these symptoms, this is when I use an antihistamine versus.
This is when I use epinephrine.
And epinephrine is the only treatment for severe allergic reactions.
It is the only one, really.
Everything else that's given is secondary to relatively minor symptoms.
So you can't Benadryl your way out of anaphylaxis.
That's not an appropriate treatment.
It's always epi first and epi fast that hesitation can be so consequential, and it highlights how much fear and misunderstanding exists even around life-saving tools.
I think which connects to one of the most hopeful areas in your field, at least from my perspective, and that's oral immunotherapy for food allergies.
For a parent maybe, whose child can't even touch peanuts, what does that treatment actually involve?
Essentially, what we do is we have you consume a small amount of that allergen, like peanut as an example, and slowly increasing it over several months to desensitize the immune system to an extent.
Kind of like the allergy shots for environmental allergens, but with food.
We're trying to trick the immune system so that if you accidentally ingest it in the field or in the real world, your likelihood of having a severe allergic reaction is diminished.
It's not necessarily a cure, but it's a way to help manage it for people, especially if they're very sensitive.
And so there's a lot of promise in using this as a tool to help managing food allergies more effectively actively rather than passively surveilling and making sure that we don't have a reaction and treating it.
So for a lot of families, it's very helpful.
On the flip side, it also can have side effects and change your lifestyle, because you have to take this every day.
You have to do certain things to make sure it's safe to do.
And that can take a toll on some people.
So it's something that I spend a lot of time talking with my patients about to determine is this the right course of therapy for them.
Because for some families, it's amazing.
Others may not be.
It just really depends on the situation.
Zach, a lot of people feel like allergies are getting worse.
I hear this all the time.
Longer pollen season, maybe more food allergies, more kids carrying EpiPens.
Is that real or are we just noticing it more?
It's definitely real.
The question is, why is this happening?
And that's not fully understood.
If we knew the why, we'd have a much better time being able to prevent these things or managing them better.
Because in medicine, when we understand the pathophysiology of the mechanisms of disease, we can then target therapies towards it.
We now have a lot more asthma therapies because asthma is not one disease.
There are multiple molecular mechanisms, we call endotyping, to figure out.
Is this due to eosinophils or IgE antibodies, as an example?
We have medications that can fine-tune target some of those things.
And so there's a lot that we can do with this.
Yeah.
And to me, it raises bigger questions about the world we're living in.
You touched on this earlier, but how our environment is shaping our bodies and climate change is increasingly part of the allergy conversation.
What does that actually look like in your clinic when it comes to pollen exposure and respiratory allergies?
Right.
So over time we are seeing pollen counts increasing as temperatures and burning fossil fuels is increasing.
So our pollen season starts earlier, ending later.
And we have really good studies to show that as you increase CO2, that's like plant food for photosynthesis it's going to produce more pollen.
And so every year I hear...
Why are my allergies worse than ever before?
So there's that positive correlation that we see there with the increase in pollen counts.
What I see now in my area in the Midwest.
Every summer, now the past few summers, we've had wildfire smoke coming from Canada, where it's blowing south and it's blanketed many parts of the country.
The air quality index is so high that a lot of people are getting sick.
And this is going to become more and more of a problem as our environment is changing in ways that are not healthy for our lungs.
We're also learning about our indoor environments as well, that even just gas burning stoves are associated with developing asthma because when you're cooking and you have that fire going, there's pro-inflammatory volatile organic compounds like nitrogen dioxide that's being released.
And if you don't have good ventilation, you're breathing it in, that's not healthy for your lungs.
We have a shift from tobacco smoking to vaping, which vaping is not necessarily a healthier alternative.
It can be just as bad and we still don't even know the full ramifications.
But we're seeing a lot of younger individuals coming with severe respiratory distress and developing these types of pneumonias that we haven't been seeing before.
So there's a lot of shifting problems there that is happening as our environment is changing and what we're doing with it.
Zach, you just mentioned earlier your new book All About Allergies, which is a New York Times bestseller.
It's written for everyone, from new parents to adults who suddenly develop allergies later in life, like me.
What's the one thing or one idea you hope readers walk away with?
The idea I really want people to understand is that these allergic diseases are highly complex.
There's a lot that we know, but a lot more that we still have to know about them.
And they need to be taken seriously because they are major quality of life issues, but also even quantity of life.
And so...
I wanna change the way that we talk about allergic diseases, because they're often not taken seriously or the butt of jokes.
And if you have a really better appreciation and understanding of the immune system and how it works and how it abnormally responds to our world, you'll gain more empathy and understanding for those who live with these issues.
I hope for people you know, after listening to this, get a better understanding and appreciation for the fact that life is a lot about balance.
We talk about medical school homeostasis, and that's very true for the immune system that you don't want to boost it.
You don't want it to be You want to have balance in life.
And I think that's a good way to live life too is that we lead by balance, and you know you're going to have stress in life, but how can we balance that out?
How can we think about the work-life balance?
And so that's all interconnected, right?
I think ultimately, what you're doing is empowering people and giving them a way to make sense of something that can feel really overwhelming for some of us.
And so looking ahead, if we fast forward maybe 10 years and imagine a family sitting in an allergist office like yours, what do you hope will be different about how we prevent, treat and then talk about allergies?
I'm hoping in the future that we'll have a better understanding of the why.
Why is this happening?
How do we prevent these things from happening?
And hopefully in the next 10 years or so, we have more disease-modifying treatments which are slowly starting to make their way.
In the end of my book, I give some hope about future directions.
What's the type of research that we're doing for these different diseases and, as an example, with food allergies, they're starting to take medications that are already fda approved and finding novel approaches to hopefully stopping food allergies in their track.
So i'm really excited with where we're going with this field.
It's a big reason why I wanted to become an allergist is seeing the tremendous amount of growth that's been going on over the years and seeing that it's a lot more than just a runny nose.
We do a lot of different things that help people feel better.
Yeah, it's it is an exciting time for sure.
And I just want to say thank you so much.
This has been such an eye opening conversation and honestly, a really grounding one for me.
So again, I'm grateful to you for sharing your time and your stories and your clarity with us.
And thanks to everybody for listening.
Thanks for having me.
And that's our show for today.
Thanks again to Dr. Rubin for joining us.
I highly recommend following him on social media at Rubin underscore allergy.
That's R U B I N underscore allergy or check out his new book all about allergies.
Thank you so much for listening.
Ted Health is a podcast from Ted, and I'd love to hear your thoughts about this episode.
Send me a message on Instagram at ShoshanaMD.
This episode was produced by me, Shoshana Ungerleiter, and Jess Shane.
Edited by Alejandra Salazar and fact-checked by Vanessa Garcia Woodworth.
Special thanks to Maria Lages, Farrah DeGrange, Daniela Balarezo, Constanza Gallardo, Tansika Sangmarniwang and Roxanne Highlash.
Thank you.
