Allergies: An Immunologic Approach
Interview with Todd Born, ND, CNS
Addressing allergies with integrative therapies is a great practice builder, according to Dr. Todd Born, a graduate of Bastyr University, scientific advisor for Allergy Research Group, and the medical director of Born Naturopathic Associates in Alameda, California. In this interview with Sarah Cook, ND, Born shares the approach he has used to successfully addressing allergies in more than 500 patients to date.
Sarah Cook: It seems that allergies are affecting more and more patients. Is that just a perception, or is the prevalence of allergies actually on the rise?
Todd Born: Allergies are definitely on the rise. True allergic diseases, including allergic rhinitis, eczema, and food allergies, are the most common health issue affecting children in the United States, and the sixth leading cause of chronic illness in adults. Allergies affect approximately 40 percent of U.S. children and 30 percent of adults. That is a huge percentage of patients, and that means that you will have many, many patients walking into your office with allergies.
Cook: Why is it that some patients who have never been allergic before end up developing allergies as adults?
Born: We are seeing this scenario more and more. I use a simple analogy to explain to patients why this happens. I tell them to imagine a cup that is half full of water. The cup represents the immune system. The water represents everything that the immune system is exposed to: air pollutants, pollen, ragweed, mold, cat or dog dander, dust mites, chemicals in personal care products, medications, food additives…the list goes on. The immune system (the cup) can only handle so much toxic and allergenic exposure (the water) before it overflows. Depending on the personality of the patient, I might even use an actual cup of water to demonstrate my point.
When the cup overflows, that represents an immune system that can no longer stay in check. The immune system is so preoccupied with the burden of toxins, toxicants, and allergens that it now overreacts to benign substances. That is the definition of an allergy. Compounds that never triggered an allergic response before, now do. Suddenly, patients are experiencing red and itchy eyes, sneezing, nasal congestion, rashes, urticaria, foggy brain, sinus headaches, or throat swelling in response to foods that never triggered a reaction in the past. Essentially, they are now becoming more allergic in general.
Cook: Great analogy. Is that the same reason that some patients see their allergy symptoms get progressively worse year after year?
Born: Absolutely. We are being exposed to more and more toxic chemicals in our environment, which can have a cumulative effect on our immune system. More than 83,000 chemicals are registered with the U.S. Environmental Protection Agency (EPA)—many of which are known to disrupt our neuroendocrine, immune, and detoxification systems.
I also see allergies intensify after people go through periods when they are not taking good care of themselves or when they are under more intense stress. A good example was a patient I saw right after the holidays. For a couple of weeks, she had been traveling, sleeping in hotels with fresh-scented linens, eating poorly, not exercising, etc. Her allergy symptoms were on fire.
Cook: What are the most common causes of allergies?
Born: Many different compounds can trigger allergic reactions: airborne allergens (such as pollen, mold, dust mites, or dander), contact allergens (such as latex or chemicals), food allergens (such as peanuts or shellfish), or medications (such as penicillin).
The most common type of allergies are inhalant allergies, caused by compounds in the air. Pollen from trees, grasses, or ragweed triggers allergic rhinitis or eye symptoms in as many as 20 million U.S. adults and 6 million U.S. children.
True food allergies affect children more often than adults. There are eight foods that are most likely to cause allergies: milk, soy, eggs, wheat, peanuts, tree nuts, fish, and shellfish. More foods can trigger food intolerances or sensitivities, but it is important to be clear that these reactions are not true food allergies.
Cook: Why is it important to distinguish between true food allergies and food sensitivities?
Born: I think it is critical to be exacting with our terms. I notice that many clinicians like to use umbrella terms, but there are actually three distinct types of reactions a patient can have to foods: a true food allergy, a food intolerance, or a food sensitivity. Each type of food reaction is mediated by different chemical pathways and produces different symptoms. Although the treatments overlap, they are not exactly the same.
True food allergies are mediated by immunoglobulin E (IgE) and are a Type I hypersensitivity. Symptoms occur within minutes to hours of eating the offending food. Reactions can be mild, such as a red rash around the lips, itching in the mouth or ears, or skin flares of eczema or hives. Of course, anaphylaxis is the most serious manifestation of food allergies, producing swelling of the lips and throat that leads to trouble swallowing, difficulty breathing, hypotension, loss of consciousness, and even death.
Food intolerances produce symptoms that are localized to the gut. The most common food intolerance is lactose intolerance, which is mediated by an enzyme deficiency (lactase). Food intolerances can also be specific reactions to food ingredients, such as sulfites or monosodium glutamate (MSG).
Food sensitivities are more nebulous. Clinical trials do not agree on whether or not food sensitivities even exist, although most clinicians would agree that we see them in practice all of the time. Food sensitivities may or may not be immune-mediated, but when they are, they are a Type III hypersensitivity, mediated by immunoglobulin G (IgG). Because this is a delayed hypersensitivity reaction, the symptoms can appear anywhere from one to three days after eating the food. Symptoms of food sensitivities are also more vague and varied than true food allergies. They might lead to skin rashes (similar to true food allergies), but they might also lead to any number of other inflammatory symptoms, like joint pain, headaches, brain fog, or worsening autoimmune disease symptoms.
One benefit of being exacting with our terms is that it really does gain the trust of the patient. When I explain to a patient exactly what type of food reaction she has, she is much more adherent to the treatments. Clear explanations and specificity are powerful tools to promote patient compliance.
Cook: So the diagnosis really does matter. If a person has allergic symptoms, what is the best way to determine what he or she is reacting to?
Born: Again, the approach to determining the cause depends on whether we are looking at an inhalant allergy, a true food allergy, a food intolerance, or a food sensitivity.
Inhalant and true food allergies can be tested with an IgE skin prick test or blood test from a conventional lab. I order the ImmunoCAP Regional Profiles from Quest Diagnostics, LabCorp, and other conventional laboratories. There are a few key details to be aware of when ordering this test. First, be sure to order the correct region because different areas of the country have different plants and exposures. I practice in the San Francisco Bay area, so I test for region 14. Second, be sure to use the custom CPT code so that the test will go to ImmunoCAP rather than to the general lab. You can access the specific CPT code from the lab’s website. And third, use the ICD-10 code T78.40XA (allergy, unspecified, initial encounter) so that the test will be covered by insurance.
The reason I recommend the ImmunoCAP test is that it uses extremely sensitive reagents. The ImmunoCAP is a very reliable test for most patients. The main reason it might not detect an allergen would be if the patient is taking corticosteroids or other immune-suppressant medications.
When it comes to food sensitivities, the gold standard for diagnosis is the elimination-challenge diet. This can be effectively done in most adults, but it is often trickier to accomplish in children. Another way to identify food sensitivities is with an IgG blood test. The IgG test is controversial, however, because the results are not always reproducible. To be clear, this test has only shown clinical benefit, in human trials, in patients with one of three conditions: chronic migraines, eosinophilic esophagitis, and irritable bowel syndrome (IBS). Only in these conditions have clinical trials shown IgG blood tests to identify foods that lead to clinical improvement when removed. Still, I do run this test in patients with other conditions. I have seen decent clinical correlation and improvement in clinical outcomes when the offending foods are removed for four weeks, and then reintroduced.
When I run an IgG food-sensitivity test, I use Genova Diagnostics’ IgG Food Antibody Assessment. If it does not detect a reaction that we suspect (for example, if a patient appears to be reacting to milk but it does not show on the test), I believe it is completely acceptable to remove the suspected food presumptively. Remember, the IgG blood test is not 100 percent reproducible, and should be interpreted in the clinical context of the individual patient.
Cook: OK, great. Let’s move on to your approach to treating allergies.
Born: Absolutely. I take an extremely systematic approach. The first visit is focused on diagnosis and identifying triggers for allergic symptoms. I tell my patients it is a “Choose Your Own Adventure” because I give them the option of doing blood testing, elimination-challenge diet, or both. Once we identify the allergens, we move to the first step of treatment: remove the obstacles to cure.
Removing the obstacles to cure means removing exposure to the suspected allergens as well as minimizing exposure to additional toxicants and irritants in the environment. This step is critical to a successful outcome.
I have a handout that I give to patients to teach them how to remove the obstacles to cure. I call it How to Allergy-Proof Your Life. The recommendations include vacuuming with a HEPA filter every week, washing linens in hot water every week, placing pillows in a hot dryer for 20 minutes every week, wiping dusty surfaces with a damp cloth every week, using humidifiers, keeping houseplants, and opting for natural cleaning products. I advise against antibacterial soaps and recommend fragrance-free and chemical-free personal care products. These are foundational recommendations to help lower the toxic load to the immune system when treating patients with allergies.
COOK: Once you remove the obstacles to cure, what is the next step in addressing allergies?
Born: The next step is to balance the immune response. Allergies and atopic diseases are inflammatory conditions that involve a shift away from the T helper 1 (Th1) response and toward a more predominant T helper 2 (Th2) response.
The conventional treatment of allergies relies on over-the-counter or prescription antihistamines, which do nothing to balance the Th1:Th2 response. They act like a Band-Aid to suppress symptoms. Natural antihistamines provide a safer option that not only decreases the histamine response, but also drives the Th1 response and calms the immune system.
Cook: Taking the approach of balancing the Th1:Th2 response makes a lot of sense. When might you need to add additional treatments?
Born: That is a great question. It is important to note that you should never move on to additional therapies until after balancing the Th1:Th2 response for at least two months. I made this mistake when I finished my residency and first started to practice on my own. I had learned about sublingual immunotherapy to treat allergies, and I started using it with my patients. I couldn’t understand why many were getting worse. So I started to read more about the biochemistry of the immune system, and realized that we need to first balance the Th1:Th2 response before moving into allergy desensitization protocols.
When used appropriately and at the correct time in treatment, however, allergy desensitization protocols can be a reasonable step in the overall allergy treatment process. Allergy desensitization relies on low-dose antigen therapy to induce oral immune tolerance.
Subcutaneous immunotherapy (SCIT, or allergy shots) is a standard conventional treatment for inhalant allergies in the U.S. They have been reported to have an 85 percent success rate in reducing symptoms of allergic rhinitis in patients with inhalant allergies, but they can be painful and run the risk of causing anaphylaxis. Also, although allergy shots can help a lot of people, evidence suggests that they are clinically efficacious only in asthma, allergic rhinitis, and insect-venom reactions.
Sublingual immunotherapy (SLIT, or allergy drops) is the most common approach to treating allergies in countries outside of the U.S. One form of SLIT that is available to American practitioners uses homeopathic dilutions of allergens to induce oral tolerance.
Cook: Beyond balancing the immune system and allergy desensitization, are there any other treatments to consider for allergies?
Born: It depends on the patient. In cases that are more extreme, we often need to go deeper. We may need to do protocols to heal intestinal permeability (leaky gut) or to detoxify the liver and kidneys. As an example, I often recommend detoxifying protocols for patients who have multiple-chemical sensitivities. These are the patients who react to seemingly everything and get, for example, migraine headaches from fluorescent lights at the grocery store. To help detoxify and lower the body burden, I recommend castor oil packs, Epsom salt baths, infrared saunas, and detoxifying foods.
I’ll give you an example of a patient who needed deeper treatments to fully address her allergies. She had extreme dermatographism. Her skin would swell and turn bright red simply from putting on a shirt. This was such an extreme case that we could literally write words on her skin. She had been on diphenhydramine (Benadryl) for 15 years but continued to have symptoms. During flares, she would turn into one giant welt and would have to go on prednisone tapers. In her case, I decided to recommend a gut-healing protocol. We did a protocol for dysbiosis and then for intestinal permeability to rebuild the integrity of the gut. She is now in her third month of a gut-rebuild protocol (along with all the aforementioned interventions) and is doing better than ever.
In cases that need to go deeper, there are two things to remember: First is to take a stepwise process and only proceed to these protocols after first balancing the Th1:Th2 response for at least two to three months; second is to be clear with patients that they will need to follow a protocol for approximately six months to truly detoxify or rebuild. When they know they are committed to six months (and not a lifetime) on these protocols, they will be committed and compliant with the plan.
Cook: These are some great clinical pearls. Briefly, do you approach treatment of allergies any different in children than you do in adults?
Born: The approach is the same. The elimination-challenge diet may be more difficult in some children, so I am more likely to run the ImmunoCAP and IgG blood tests with children. Probiotics come in powders that can be mixed with soft food. Fish oils come in liquids, and children only need to take a small amount. Aller-Aid L-92 comes in a capsule that can be opened and mixed into a smoothie or juice.
I had a 5-year-old patient with such extreme eczema that she was a regular at the Children’s Hospital emergency room in Denver. We used the protocol and she got much better.
Cook: You have shared a wealth of information here. What would you want to tell doctors who are just getting started in regard to treating allergies?
Born: Allergies are a great practice builder. Allergies are extremely prevalent, people are searching for alternatives to conventional antihistamines, and they see immediate results with natural protocols. There was a study published in the Lancet in 2017 that showed an increased risk of Alzheimer’s disease in patients with chronic use of antihistamines.