Food Allergy Counseling: Interview with David Stukus, MD
I first noticed Dr Stukus on my Twitter feed (@allergicgirl). An allergist based out of Nationwide Children's Hospital in Ohio, Dr Stukus’s feed is filled with practical advice about environmental allergies, food allergies, asthma and eczema i.e. atopic disease. He tweets about talking with patients and patient education in a real and relatable way like when he reminded us all of risk factors for a teenager with food allergy.
See this example:
Recently met new #foodallergy patient with every risk factor for death: teenager, nut allergic, doesn't carry epi at all times, has asthma
When I discussed those risk factors, it really got their attention (and that of parents) - important discussion to have #foodallergy
I also noticed that he was regularly myth busting about atopic disease. Have a look at some of these tweets about alternative treatment for IgE mediated food allergy:
Dear patients with true IgE mediated #foodallergy who seek 'treatment' at a chiropractor: This will not go well for you.
Difference of opinion begins with definition of #foodallergies. I'm talking IgE mediated immunologic reactions...
Dear practitioners 'treating' #foodallergy w/spinal manipulation: Stop. Leave these people alone. Make your money somewhere else.
And late last year, in November, he made national news with a presentation he made at the American college of Asthma Allergy and Immunology: Allergy myths busted: Guess what you didn't know about gluten? - TODAY.com. His myth busting included some of my favorite myths that I hear all of the time like, “you can’t be allergic to my dog, she’s hypoallergenic.”
To that Dr Stukus wrote:
Myth 1: If you’re allergic to cats or dogs, it’s best to stick with hypoallergenic breeds.
Actually, there is no such thing as a hypoallergenic pet, Stukus says, because “every single pet will secrete allergens.” And it doesn’t make much of a difference if the pet has short or long hair, because the dander that people are allergic to doesn’t come from the fur – it comes from the animal’s saliva, sweat glands and urine.
Which I tell people all of the time but they never seem to get.
I wanted to know more about the doctor behind the myth busting and tell-it-like-it-is-tweeting allergist. So recently, I had a chance to ask him a few questions.
Allergic Girl: What’s your professional background?
Dr David Stukus: I am a board certified Allergist/Immunologist and Pediatrician. I am from Pittsburgh, PA originally, and I attended undergraduate and medical school at the University of Pittsburgh. I completed my pediatric residency and spent an extra year as Chief Resident at Nationwide Children's Hospital in Columbus, Ohio. I completed my fellowship in allergy/immunology at The Cleveland Clinic Foundation and then joined the staff at the Children’s Hospital of Pittsburgh for three years before moving back to Columbus and Nationwide Children’s Hospital in 2011.
AG: Do you have any personal connections to food allergy? To allergy? To asthma? To eczema?
DS: I do not personally have any types of allergy or asthma but my 4 year old son has asthma and eczema. No one in our family has any type of food allergy.
AG: What drew you to Allergy/Immunology as your field of specialty?
DS: During medical school, I wanted to become a pediatric cardiologist, but this interest ended very early during my intern year after reading hundreds of cardiac rhythm strips at all hours of the night.
I then became very interested in asthma after caring for so many children with asthma in various settings. Asthma is a leading cause of emergency room visits and inpatient hospitalizations at almost every children’s hospital. I became fascinated with the variety of patients, different presentations, and how difficult it is to control. When I explored specialties that care for asthmatic children, I then became very interested in food allergies, immune deficiencies, and other allergic conditions.
AG: You’ve written a lot about allergy myths, where do you think they come from and how are they perpetuated?
DS: Some of them come from physicians who continued to practice outdated medicine or continue to make recommendations that have been disproven through research. Other myths are like any urban legend, which start by word of mouth and take on a life of their own. I also believe the growth of the internet has perpetuated and also started many myths. The internet can be a wonderful resource but is not regulated in any way and is filled with misinformation.
AG: What do you recommend to your patients when confronting friends and family especially when they insist they know the “truth”?
DS: I try to educate my patients and families as much as I can with evidence and even some talking points to discuss with others for certain situations. I recommend trying to remove emotion from any conversation and to use any difference of opinion as a starting point to engage in discussion that can help provide education and awareness to both sides. Everyone comes out a loser in a shouting match.
AG: Let’s talk about IgG, IgA and IgE – what are all of these letters and what do they mean in food allergy blood tests?
DS: Ig is the abbreviation for ‘immunoglobulin’, which is the technical term for antibodies. Antibodies are part of our immune system. The letters A, G, and E all indicate different types of immunoglobulins, which have different roles inside the body.
IgA is an antibody that lives mainly on the surface of the upper and lower respiratory tract, including the nose, sinuses, throat, and lungs. IgA serves as a first line of defense and protects against bacterial infections.
IgG is a memory antibody that forms after exposure to vaccines, infections, and any environmental exposure, including foods.
IgE lives on allergy cells called mast cells, which are found everywhere throughout the body.
IgE is involved in the hypersensitivity response to allergens, including airborne and foods. If someone forms IgE towards an allergen, then exposure to that allergen causes the mast cells to open and release chemicals (histamine) that then produce symptoms of an allergic reaction.
AG: What are the myths around these blood tests and why do you think they persist?
DS: There are several myths surrounding these blood tests and most persist due to personal or financial gain as practitioners or laboratory facilities can make money by ordering extensive testing, which may have no utility whatsoever.
In regards to food allergy blood tests, IgA has no role. IgA plays a role in celiac disease, which is not a food allergy, but an autoimmune condition where some people produce IgA that attacks their own intestinal cells in the presence of gluten.
IgG is not a validated or recognized test for the detection of food allergy. The governing bodies of AAAAI and ACAAI both discourage use of food specific IgG testing in the diagnosis or management of food allergy. Most experts agree that this likely represents a memory response, thus higher exposure to a certain food will produce a higher IgG level. IgG is also formed when people undergo immunotherapy and develop tolerance to an allergen, thus suggesting that IgG is actually protective and not involved in any type of allergic response or intolerance.
IgE blood tests by themselves measure sensitization and are not diagnostic for food allergy. They are not a good screening test due to high rates of falsely positive results that often lead to diagnostic confusion and unnecessary dietary elimination. Blood IgE tests are very helpful in confirming a suspicious history of food allergy reaction or following levels over time in someone with known food allergies to determine whether they may have developed tolerance.
AG: Which letters are most important if you suspect you have a severe food allergy?
DS: IgE is the only antibody involved in an immediate onset hypersensitivity (anaphylactic) response to foods.
AG: What is the gold standard for food allergy diagnosis?
DS: The gold standard is the history of what happens when a specific food is ingested. If someone has a food allergy, then they develop an immune response to that food. This is then reproducible with every single exposure, with characteristic symptoms such as itchy skin rash called hives, swelling, vomiting, and can progress towards difficulty breathing/swallowing, loss of consciousness and even death.
If someone can eat a food but doesn’t have any symptoms, then they are not allergic to that food. In addition, if someone is having chronic symptoms (stomach pain, diarrhea) that happens no matter what they eat, then they also do not likely have a food allergy and need to consider other underlying causes of their problems. Lastly, the longer the list of suspected food allergies grows, the less likely it is that a person has true allergy to all of those foods and the more likely it is that they have other underlying conditions causing their symptoms.
AG: According to a recent study (Anaphylaxis in America: The prevalence and characteristics of anaphylaxis in the United States) the three main causes of anaphylaxis are medicine, foods and insect venom. Are their myths around anaphylaxis that you can dispel?
DS: The biggest myth is in regards to treatment of anaphylaxis. Self injectable epinephrine is the first line and ONLY effective therapy for anaphylaxis. This remains very poorly understood from patients, emergency responders, and even physicians. Antihistamines and steroids are second line treatment, to be given only after epinephrine.
Another big myth is that people don’t realize death occurs from allergic reactions, with approximately 150 people dying each year from anaphylaxis.
AG: Let’s dig in the myth of the hypoallergenic pet. Where do you think this started?
DS: A lot of this myth is based upon financial gain, with some breeders and companies marketing ‘hypoallergenic pets’ to customers, which cost significantly more than other breeds. This is likely perpetuated by people who have pet allergies themselves but continue to want to live with pets.
AG: What are the realities and what the falsehoods about pet allergies? And pet allergies including asthma like mine?
DS: Realities are that any pet will release allergen into the air, which is called dander. Some people may only have allergy symptoms when exposed to certain breeds or individual pets, whereas others may have symptoms around all types of one animal. There is no test available to determine allergy towards specific breeds. The only way to know if a specific pet will bother someone is by exposure.
Pet dander is what causes allergy symptoms and this is released from saliva, urine, and sweat glands. It spreads throughout any home in which pets live and will be on clothing, deep inside carpeting, and throughout the ductwork.
The only effective way to rid a house of pet dander is to remove the pet from the home, and even then, it can take 4-6 months before all the allergen is gone. It can help to restrict the pets from the bedroom at all times, vacuum and dust regularly, and wash the animals, ideally twice a week.
Falsehoods include the belief that some pets do not cause allergies. Allergy to pets has absolutely nothing to do with hair length, shedding, or breed.
People with asthma and allergies to pets can have both long term loss of asthma control with more frequent daytime/night symptoms and also more frequent asthma exacerbations that may require emergency room treatment or prednisone.
AG: When someone, like me, has allergic asthma to pets, would a mask work to protect me or allow me to stay where a dog/cat longer? (Specifically, my father wants to know.)
DS: Please tell your father that wearing a mask is not a very effective way to reduce exposure to pet dander for reasons discussed above regarding the ubiquitous nature of microscopic pet dander throughout any home in which pets reside.
AG: What is the one question you wish every patient would ask you during a consult?
DS: What is the most important thing I can do to make sure my child stays healthy?
AG: What is the one action you wish every patient would undertake to help you help them?
DS: If we discuss a new therapy, whether it be a new medication or other strategy, I wish they would at least try it for some period of time to help determine whether it is helpful or not.
AG: What are three things to tell your food allergy patents that give them hope, empowerment or courage?
DS: You can still enjoy life if you have food allergies.
With education comes knowledge, and with knowledge comes understanding. Once you understand your food allergies, you can deal with any challenges.
While not ready just yet, there are promising new research trials underway right now that offer some hope in regards to a possible cure for food allergies one day.
Thank you Dr Stukus for all that you do for the allergy community – keep doing the great work!