#303 Allergies, Intolerances and Food Fear: What You Really Need to Know about Testing and Treatment with Dr Helen Evans-Howells

Dr Rupy: Dr Helen, can migraines and headaches be caused by allergies?

Dr Helen: Generally not.

Dr Rupy: The increase of allergies is because we're too clean. True or false?

Dr Helen: Not really, no.

Dr Rupy: If you feel better after cutting out dairy or gluten, does that mean you're intolerant?

Dr Helen: Not necessarily.

Dr Rupy: Should you trust online food intolerance tests that tell you which foods to cut out?

Dr Helen: Definitely not.

Dr Rupy: Is it safe to give babies, when they're weaning, peanut or egg before one years old?

Dr Helen: Yes.

Dr Rupy: Hi, I'm Dr Rupy. I'm a medical doctor and nutritionist. And when I suffered a heart condition years ago, I was able to reverse it with diet and lifestyle. This opened up my eyes to the world of food as medicine to improve our health. On this podcast, I discuss ways in which you can use nutrition and lifestyle to improve your own wellbeing every day. I speak with expert guests and we lean into the science but whilst making it as practical and as easy as possible so you can take steps to change your life today. Welcome to The Doctor's Kitchen podcast.

Dr Rupy: Are you really allergic to dairy or just intolerant? Can headaches, joint pain or fatigue be signs of hidden allergies? And what about those online food intolerance tests, should you trust them? Well, in this episode, Dr Helen breaks down the confusing world of food allergies, intolerances and sensitivities with real clarity and evidence. You're going to learn about whether allergies can actually show up as migraines, fatigue, gut issues or even mood changes, why allergies are on the rise, the truth about IgG testing and other common myths, whether it's safe to give young children peanut and egg, especially before the age of one, and why early exposure actually matters and how to approach things like elimination diets, food challenges, even food diaries. And we also talk about the emotional toll of allergies on families and why we actually need to stop blaming food entirely. We're going to dive into the rising rates of allergies, the hygiene hypothesis, environmental triggers, yes, even plant-based proteins, which is a really interesting angle that I haven't come across before, and what's actually working in clinics today from immunotherapy to support networks. So, if you or a loved one is navigating the food allergy maze, this podcast is going to be packed with actionable science-based insights. Dr Helen Evans Howells is a GP with a Masters in Allergy from Southampton University where she also trained and worked with the hospital's allergy team for over four years. She now runs one of the only specialist allergy clinics across the UK, offering immunotherapy for children and lectures widely across the UK and internationally. She's also a trustee for Anaphylaxis UK and chair of its clinical and scientific panel. I wanted to structure today's podcast episode as if I were stepping into the shoes of a patient going to see an allergy specialist like Dr Helen or one of her colleagues because in the NHS there's certainly a lack of these services, but even in the private arena as well, there are very few clinics that offer these services. And the prevalence of food allergies in Western countries is increasing. It affects around 6 to 8% of children and up to 10% of adults, and there is certainly a rise in food intolerances. Even though this is hotly debated and contested as to whether this is a true intolerance or allergy, I still believe that we are certainly seeing a lot more than can be explained by an increase in reporting. During the podcast we do mention a couple of terms that I also want to clarify at the start. So, atopy is a common, commonly used term. It's a genetic tendency to develop allergic diseases such as asthma, eczema, also known as atopic dermatitis and hay fever, allergic rhinitis and food allergies as well. It's characterised by an exaggerated immune response, if you like, to environmental allergens, and there's generally a family history of allergic conditions and positive skin prick tests or specific IgE blood tests to common allergens as well. And we also talk about IgE mediated and non-IgE mediated allergies. So, an IgE mediated allergy is something that happens quite quickly, usually within minutes to two hours after you're exposed to something. Let's say like a peanut or pollen or a bee sting. It involves a special antibody, part of your immune system called IgE or immunoglobulin E. And IgE tells your body to release chemicals like histamine which can cause typical symptoms. It could be hives, swelling of your lips, eyes and face, wheezing, vomiting, and in severe cases anaphylaxis, which is a really exaggerated reaction that we talk about in a lot more detail on today's podcast as well. Non-IgE mediated doesn't involve IgE and is typically slower. These symptoms can appear hours or even days afterwards and it's caused by other parts of the immune system like T cells, for example. It's harder to spot because symptoms are more delayed. It can be tummy pain, diarrhoea, skin issues, reflux, eczema in some cases. And in practice, some allergic conditions can actually involve both, which is why it's a really complicated area. They can involve both IgE and non-IgE mechanisms, especially in chronic diseases like eosinophilic gastrointestinal disorders that we do mention on today's podcast as well, also known as EOE. This is going to be, as you can imagine, a jam-packed episode. Dr Helen was super gracious with her time and her knowledge. I really encourage anyone to go check out Dr Helen on her private Facebook page that will link to in the podcast show notes on the doctorskitchen.com. You can also follow her on Instagram and you can book in to see one of her clinics. We have no affiliation with Dr Helen's private work at all. We're just really big fans of what her and her team are up to. And talking of fans of what people are up to, we're really big fans of Exhale Coffee, if you didn't know, and if you're really interested or intrigued to try Exhale Coffee, which is high polyphenol coffee that's grown at altitude to produce the abundance of antioxidants, it's organic, pesticide-free, independently lab certified to be free of those nasties that unfortunately are commonly found in coffee. You can try a bag completely for free by clicking the link in the bio. I don't know how or why they're doing it but they're giving you a bag of Exhale coffee completely free, free packing and posting, everything. It is 100% free. You will pay 0 pounds for it. Like I said, you'd be silly not to click on the link and get your your free bag of Exhale coffee because they are so confident and I'm actually so confident that if you try it, whether it's whole beans or ground, you put it into your cafetiere, you are going to be absolutely sold. It is the coffee that we have in the Doctor's Kitchen studio. It is a wonderful tasting coffee and I am a massive coffee snob. And talking about snobbery, one thing that we are also very proud of is The Doctor's Kitchen app. So if you're interested in gut health recipes, brain health recipes, heart health recipes, we do all the deep dive into the evidence, we do the back end of our algorithm, so you can confidently choose according to your dietaries, allergens, intolerances if you have them, recipes that suit your health goal as well as your cuisine and dietary preferences as well. Go check it out. Download it from the App Store or on Android, Google Play. We have over 1000 recipes, 20 new brand new recipes every single month and there is a free trial for that as well. So go have a play, try a few recipes. You won't be disappointed. That's a long intro. I really do hope you enjoy this podcast with the wonderful Dr Helen.

Dr Rupy: There's a lot of things here to unpack, Dr Helen. So, why don't we start off by talking through signs and symptoms that people may not be may not realise might be linked to allergies and intolerances. I know you said migraines and headaches are not generally caused by allergies. Are there things that perhaps we wouldn't think of that are actually related?

Dr Helen: Yeah, I mean allergy, I think is a field which is evolving more and more. So, over the times that I've been a practicing doctor, there are new diagnoses that we'd perhaps had never heard about. So, there's the kind of more mainstream allergy that we refer to as IgE mediated allergy. So, it involves the immune cell immunoglobulin E and those are the allergies that give you symptoms very quickly on exposure to the same food each time, so peanut often people think about, that gives you like a nettle sting rash, hives, swelling, vomit, tummy ache, diarrhoea, sneezy, congested, anaphylaxis. Then there is what we refer to as non-IgE, so it doesn't involve that immune cell immunoglobulin E, but allergy means it's involving the immune system and they tend to present in infancy. So, more gut symptoms, diarrhoea, reflux, very unsettled babies, congestion, difficult to manage eczema. Okay. Then there's a form called FPIES, which stands for food protein-induced enterocolitis syndrome. So, many people including healthcare professionals haven't heard of that one. And that's where you get one to six hours later profuse vomiting and often that young is usually in a child but there are some forms in adults that mean that they become extremely sick and actually it's quite a scary reaction to witness. Okay. And some get diarrhoea with it. So, I think people don't often know about that one, because they then get mislabelled as it was an infection or gastroenteritis or a tummy bug or something when it wasn't. And then there's one called eosinophilic oesophagitis, which still falls into the allergy format where people get reflux, indigestion, vomiting and food getting stuck. And those last two ones, I think are, um, diagnoses that definitely have evolved over time and I was not aware of them going through med school or in the early years. And I and I look back now because I did quite a few years of ear, nose and throat surgery and I remember all the people coming in with food boluses where food would get stuck and you would say to them like chew your food more, what I'm still always saying to my stepson, George. But actually, a good proportion of them may well have had eosinophilic oesophagitis. And you won't know unless you take multiple biopsies of the oesophagus. And all we did when we, disimpacted them in ear nose and throat was probably pull it out or push it down. But we didn't necessarily biopsy, whereas now if you have a food bolus, you really should be encouraged to be explored. And EOE, which is the short version for eosinophilic oesophagitis is often overlooked. So, if you're not responding well to like the traditional medications like omeprazole that treat your indigestion and you've got particularly food getting stuck, you're a slow eater because you know that's what you need to do, you know, you need to be thinking, could that be EOE, but you'll only know by having a gastroscopy, so a camera test down your throat into your stomach and multiple biopsies because you can some areas can look normal and others can be abnormal. Wow. Sometimes I used to wonder whether I have that, but I I'm hoping I don't, but I am quite an atopic person. I have asthma, you know. And, um, so it's not unusual that I'm the last person eating and that I get quite bad indigestion that nothing treats, but it's hard to go and have a gastroscopy done, but sometimes I wonder. But yeah, it's definitely those latter two diagnoses are overlooked often.

Dr Rupy: It sounds A very difficult to diagnose as well if you've got to do multiple biopsies. Yeah, you've got. Uh, and I mean, I I certainly have come across a number of different patients who have had food boluses and I remember just thinking to myself, why aren't people chewing their food properly? And I feel kind of embarrassed now actually because I don't think I I ever thought about eosinophilic oesophagitis. Yeah.

Dr Helen: I know, and also like I I this is why I always when I'm talking to colleagues about and teaching trainees, say like just because we don't know the answer to something, it's really important that we're not dismissive of people. Um, and I think it's really important to be open-minded and just explain, I don't have the answers for you, but it doesn't mean that what you're experiencing is not accurate. Because I remember thinking of like some of the young women that had like reflux that wasn't going away, that they consulted multiple, multiple, multiple times and you'd be you'd in the end you, it's a junior doctor thinking, oh, they're a bit crazy. Whereas now I think, oh my God, like how many of them were you overlooking? And I think those, um, experiences, because we all mature in life, that's the reality. I'm a very different person to how I was 20 years ago. You think I wonder now whether we miss their diagnosis and they weren't getting the help they needed because it can look visually normal when you look down at a gastroscopy, doesn't or you can get narrowing but it doesn't always look like that. Okay.

Dr Rupy: So it's literally going to be biopsy the whole way. even if it's normal looking.

Dr Helen: You've got to take multiple. I think it's five. So it tends to be gastroenterologist that specialise in that area and you'll get some that specialise in EOE. Um, and so some gastroenterologists may not think to do the biopsy. So if you're a GP listening and it's on your radar, mention it on the referral, um, so that they know to look for it. Okay.

Dr Rupy: In the spirit of being open-minded, Yeah. um, headaches and migraines, Yes. um, you mentioned that it's not generally caused by an allergy or intolerance to food or or other allergens. Um, is it something you've ever come across before? Is there a relationship?

Dr Helen: So I say not necessarily by an allergy. The the times I've seen it really with headaches would be more people who have environmental allergies. That's why I said not really. So if you've got significant congestion from grass pollen or house dust mite, whatever it might be, and that can give you facial swelling and sinus pain, then yes, you can get headaches from that reason. Generally with foods linked in with allergy, I would say no, it's really not a common, um, feature that people give you. Um, I mean, in the moment of experiencing a systemic, so a sort of anaphylaxis, you you're going to feel quite rubbish, but headache is not a key feature. An intolerance, of course, the definition of that is a reproducible adverse reaction that doesn't involve the immune system. And many times over, we don't actually know the mechanisms involved. So if you said to me, every time I eat bananas, I get a headache and it happens every time. Well, then I believe you. We probably don't know what that mechanism is. I might make a guess about what it is, but I might not know. And so then I would term that an intolerance. If you've told me it's happening, I've got no reason not to believe you. I just maybe can't give you a a specific scientific answer about the pathway. But with allergy, unless it's environmental, I tend not to link the headaches.

Dr Rupy: Let's unpack some of this terminology that we're going to be going through for the remainder of this pod, allergy, intolerance, sensitivity. What are some of the key definitions that we should know?

Dr Helen: So as I sort of mentioned, allergy is reproducible, i.e. it happens every time you eat the food, adverse reactions. So that's just something happening to you that's not pleasant or can have a significant impact, which involves the immune system. So your immune system is identifying a food as harmful when of course it shouldn't be. An intolerance basically is everything else, um, a reproducible adverse reaction that doesn't involve the immune system. And I can say many times over we really don't know enough about those mechanisms. And we're all different and I think I see a lot in clinic where people because we are, you know, we want to help ourselves and we want to be well as a society mostly. And so we look for pattern recognition. But sometimes you add two and two together and make five and it isn't always happening. And so having an objective brain to ask you to retry or look at an ulterior diagnosis is what we need. And sometimes in a consultation we come to the point of like, I don't agree with your theory and but I would hope that we can communicate well to go, it's okay that we don't agree. Um, this is how we'll move forward with it. Um, and sometimes we just don't agree with each other. That's okay, as long as you're not dismissive to people. Um, so yeah, those are the two main and I guess sensitivity. I don't know if what the strict definition is what I would think of as sensitivity is that food is not agreeing with you. Would that arguably be an intolerance, probably? And it's just an interchangeable term.

Dr Rupy: Yeah, I've always lumped them together in my mind even though we do have like official definitions using the word sensitivity like non-celiac gluten sensitivity. Yeah, of course. Um, but I've always thought of that in the same vein as you as, okay, this is outside of the immune system. Hence why it's more likely to be an intolerance or maybe I'm getting it confused.

Dr Helen: Yeah, no, I think that's where I would put it as well. And of course, Celiac it's hard to know where that fits because it's slightly different again in that it's autoimmune, so it is, but it's not traditionally what we think of as allergy. It's different. And and I think that's sort of nods to the evolving nature of it. So we know that with Celiac disease, you can't tolerate gluten, but as you just said, there is non-celiac gluten hypersensitivity where we see quite extreme symptoms sometimes from people having gluten. And they really are so much better without it, but we can't identify that pathway yet.

Dr Rupy: Yeah. Yeah, yet. Um, so yeah, so we we mentioned gastritis really important with EOE. Um, what about vague symptoms like fatigue or um, even joint pain, brain fog, a lot of people are searching for answers to to these symptoms online and they sort of go down the pathway of is this my immune system?

Dr Helen: Yeah, they do. and I think it is fascinating being so involved in allergy because what I've really noticed is how much we blame food as the cause of everything. Um, everything. I see such a spectrum of people coming saying it's allergy and sometimes I'm just sit there and go, what? Um, you know, and of course we'll still approach the consultation in the same way and help you unpack and sometimes people leave understanding why I really don't think that is allergy. But we do blame a lot on our food and sometimes it really is isn't, you know, to cause. Doesn't mean you can you shouldn't live a healthy lifestyle, of course, but that it's not causing, you know, your rheumatoid arthritis for instance, where I've had people asking me about that. Um, so, but yeah, it is there are some symptoms. So, you know, for instance, if someone's got a significant fatigue, I might be thinking, have you got environmental allergies because the impact of that on some people is huge. I remember a few years ago seeing a young girl, quite active, like eight, so no reason why she would just suddenly stop all her dance classes. Her mum was describing she would just sleep in the day and it had been overlooked the extent of her house dust mite allergy. and it was really affecting her quality of sleep. So we just put in all the measures to treat that properly. And her mum messaged me like a few weeks later saying she's just a different child. Wow. So I do see fatigue as a huge issue. And if you're a pollen sufferer and I am, I know during grass pollen season, I will feel quite different to how I'll feel outside of that. Whereas if you've got house dust mite allergy for instance, or your pet at home, you probably won't notice the difference. So you'll overlook that that could be causing fatigue because you live with it day in, day out, whereas pollen there's such a defined change, you'll notice that you feel awful during the pollen season if you've got severe disease. I don't really see otherwise, certainly not with allergy that fatigue is a huge feature of that. Um, but I think that in young children when they've got gut symptoms or chronic tummy pains, so chronic in the medical definition means long-term, you know, they've been going on a long time, that can be overlooked sometimes and actually the problem is a non-IgE allergy that was missed from early doors or is still there. Um, so sometimes really breaking that down, you can make a huge impact to their life if you identify what food needs to come out.

Dr Rupy: Yeah, yeah. Um, you mentioned environmental allergens there. One of which is, uh, house dust mite. mite. Um, what other environmental allergens are you seeing cropping up that perhaps people wouldn't realise?

Dr Helen: So the common things, house dust mite and your your animals of course, whether you live with them or someone else and that can be quite problematic. Um, grass pollen, um, different types of tree pollen. We're getting more weed pollen allergies in the UK with the change of climate. So if you are someone that's got quite significant symptoms in August for instance of hay fever, it's probably not grass because the grass pollen season tends to end in the end of August July. Um so if you're going on into August then that heat, it's often mugwort, so a weed. And that hotter climate that we're experiencing is why we're getting more of that in the UK versus perhaps other countries. Right. And then into the autumn, you might have moulds. There are a variety of different moulds. So they're tend to be the moulds that are found outdoors, but of course you can find them in your home. So alternaria, aspergillus, cladosporium, penicillium. Um, they're not as common as the pollens, house dust mite and then the animals as well, which can be quite affecting really. And, um, had a lovely lady come and see me this week who had a dog, you know, really helping her mental health. She knew she was allergic, but living with it has brought on a different level of her allergy than perhaps, um, just visiting people's dogs. And she said she'd been for an NHS appointment and they'd just said to her, 'Well, it's obvious, get rid of the dog'. And that was it and they didn't even test to prove that that actually was the cause of her problems. And I was quite, and so she said, the reason she'd picked to come and see me is because on my website, it talks about the fact that my daughter, Florence is actually allergic to our animals, but we still have them. And we look at how we can combine living with our animals that we love dearly. And of course we do love her most of the time. Um, and so yeah, we had a conversation about actually what strategies can you put in place? Can you keep your animal? Now, if you've got hideous asthma and you're having multiple admissions and steroids, then I probably am going to have a conversation with you about this is not very sensible and will put your life at risk. But if your symptoms are more congestion, itching, sneezing, I think it's a choice. Yeah. Um, just like for some people, they know that eating that food is going to keep giving them gut symptoms and they choose to. And it's that balance of harm and we're all individuals and we're allowed to make that choice and Florence chose and nagged for me to have dogs and hence we do. But you know, she does react to them.

Dr Rupy: I I've got a little dog and if I developed an allergy to her, there is nothing that would get me to kick her out of the house. She's staying with me.

Dr Helen: If you're not a dog lover or a pet lover, you don't get that.

Dr Rupy: You don't get it. No, no, no. And I didn't used to get it. Honestly, we've only had my dog for like five years and prior to that, I wouldn't have understood what I'm literally saying now. And now I get it. Yeah.

Dr Helen: Now you have your own. But of course, for some people, their symptoms are so severe. So I've had, I can think of lovely circumstances where perhaps the spouse is really struggling. And often what happens is when they go on holiday, it really highlights to them how significant their symptoms are. And he travelled quite a long way to come and see me and basically his when it comes to the it's me or the dog, his wife had said, well, it's the dog. Um, which is funny, but it's not actually funny when you live with it. And so I really felt sorry for him because I was, you know, he probably needs immunotherapy to desensitise, but that's tricky when you're already living with dogs. So it's really tricky. And then for other people who can't live with an animal and they know that say they or their child can't, going to see people with animals is very difficult and will be quite, can mean that leads to exclusions from parties and visits because you can't go to their house and family members. Um, and some people do have quite significant asthma that's triggered by dander, particularly cats and horses. And so now if you're sitting next to that person at work who's covered in cat hair, it sounds funny to us, but it's not actually funny when you're living with it. Um, I know my colleagues on the NHS said they once desensitised a paramedic against cats because every time he went in a house with cats, he had anaphylaxis. Oh gosh. So it it yes, we using it in humour because that's what we do often as doctors, but actually there's a spectrum of disease and for severe disease, it really affects people's lives and people don't get that because they're like it's an animal, but it can, you know, still trigger severe reactions.

Dr Rupy: I I want to take a bit of a step back just to put a spotlight on just how big a problem this is actually because I think, you know, it's easy to be in a bubble and and you know, as a general practitioner, you you see allergies, you're like, oh yeah, there's sort of increasing. I'm seeing more now than I I was at the start of my career. But, um, there was this Lancet paper that we discussed just briefly before that showed this instance of new diagnosis of probable food allergy doubling between 2008 and 2018. So this is a a real big problem that is on the rise and we're seeing, you know, high rates of asthma, uh, different types of atopy. Um, what is what is going on?

Dr Helen: What is going on? I know it is huge. So it was a study by Paul Turner and what it did was it looked at coding within general practice. So it was as good as we could get. So they looked at possible food allergy, probable food allergy and probable food allergy with an adrenaline injector so an epi pen or a jext. So you could assume that if they've got an epi pen, they really do have allergy. Although I would say unfortunately allergy education is really poor. So actually the likelihood of all of those diagnosis being correct is is not good. But actually they compared it to the past with those same diagnoses and you could see a big shift. It has stabilised, but of course some of the data roles into Covid. So we don't quite know. So it's not it doesn't look like it's continuing to rise. It looks like it's static, but is much it's quite different from how it looked 10, 20 years ago. And we don't really know. That's, you know, there are lots of theories about why. Um, some of that, you know, a lot of that is around gut health and the changes of our diet and the importance of a happy microbiome and happy bacteria. Um, there is a piece around the fact that we've done a bit of avoidance of certain foods which can seemingly cause more allergy to form. Um, but we don't know the full story of why is it more likely. But you know, you're talking about 5% of children and one to 2% of adults and that's food allergies. Then we if we look at environmental allergies, 30 to 40%.

Dr Rupy: 30 to 40%?

Dr Helen: Yeah, it's huge. And then if you think about the fact that on our undergraduate curriculum, so at university, you get one day of allergy. It's absolute nonsense. And until I so I was chair of the primary care group of the British Society of Allergy and my colleagues had already been doing some work, so I just came in at a time where we were bringing it to the sort of crux, but it was only a few years ago that food allergy got put onto a GP's curriculum to learn about and that has in the last year been increased, so there's now more on it. But they didn't need to know about it. So when my son was diagnosed with food allergies, I wasn't a full GP, I was training at the time. But it was no wonder that me and his GP would sit there and go, hmm, what do you think? You know, and we didn't just didn't know. And that's why you will meet a big proportion of GPs who don't have the full training. But it's not just GPs, A&E doctors, you know, you often go to A&E and think, oh well the A&E doctor told me, but they're often very junior doctors. Sure, yeah. The, um, health visitors, the nursing, it it's a a problem across all of healthcare that needs a huge change really to increase that awareness. And us as the public to be more aware of, um, what allergies are, be empathetic, stop this nonsense that you see that allergies are being the the brunt of jokes. I saw more stuff on that last week about some American like making jokes about peanut allergy for instance. And I even our own, um, presenters do that a bit on telly. And if your child died on an airplane or your relative or they're now brain damaged, which has happened, not funny. I just don't get how it can be the brunt of jokes when we wouldn't allow that for people of, you know, in a wheelchair or colour, but yet if you've got food allergy, you can be the brunt of a joke. So my son had milk allergies and we watched Box Trolls. I don't know if you've seen that. It's a film. Um, it's a good film, it's a children's film.

Dr Rupy: All I watch these days.

Dr Helen: And the baddie, and it's always the baddie, Farmer McGregor and Peter Rabbit had a blackberry allergy. But he um was allergic to dairy and they fed him cheese at the end and his brain exploded. And so if you are a four-year-old, five-year-old watching that with a dairy allergy and then you get a little one turn to you and say, 'Mummy, is that going to happen to me?' it's really, it's not actually funny and it shouldn't be allowed to be the brunt of jokes. So.

Dr Rupy: Serious question. Um, should we be allowing nuts on a plane? Is there a, is there a genuine risk for bringing that, uh, known allergen onto such a confined space for a long period of time?

Dr Helen: Yeah, it's it is really difficult. It also goes to the nut-free school question, which is quite controversial. I so I'm a trustee for Anaphylaxis UK and we don't really believe in that kind of blanket ban. Okay. And we believe in it more being a nut aware school and the same concept with airplanes. The thing is, you know, peanuts have for a long time held this kind of standard of that's the nut that's the thing to fear with food allergy because we knew that, you know, significant reactions happened and deaths have happened. But if we look at the cause of death from food allergy for children over the last 10 years, I will point out very rare thankfully, but it's milk. And so the question sort of is of how far do you go in banning foods given that they're most people could be, you know, people could be allergic to most things, not everything, but most things. So I don't really agree with banning one thing over another thing, but I feel like we need more compassion and awareness. So, um, what's sort of talked about is rather than a blanket ban on the aeroplane for nuts for instance, or whatever the food might be, that they set up a buffer zone so that the areas just in front and behind and next to them are free from that product. The reason particularly with nuts, but actually even with milk is because it's a very sticky protein and it's left behind everywhere in residue. There's a study with peanut showing that when it was kind of used on a chopping board in a house, when they hoovered the person's mattress, they found peanut protein there because it travels everywhere.

Dr Rupy: Oh my gosh.

Dr Helen: So when people are reacting on aeroplanes, the likelihood is that they're touching surfaces because even today I sat on the train and opened my train it's covered in mess and that's just common, isn't it? On airplanes. They're not cleaned well, that they're probably coming into direct contact with the food, so touching it, touching their mouth. So better cleaning would be great. The studies would suggest it doesn't become airborne and they've they've measured that. So they sort of open peanuts and if you directly measure just above the bag, you'll measure protein, but a little bit higher and you won't. Right. So the only kind of allergen we really feel becomes airborne is around the fish and I noticed there was a um, a label on the wall about seafood. So I would have more concern around seafood and and fish. Um, and I think that would be very reasonable then that you would ask that airline not to if it was truly airborne. Yeah. But because many people live with those myths themselves and don't really know what's happening, then the airline couldn't possibly interpret truth or not. And also they're not doctors, so it's not their role to to not agree with the person telling them. Same as in schools. If you go to school and say, my child's got an airborne allergy, it's not the teacher's job to question it. Yeah. And it can be a tricky conversation to have with a person of why I don't necessarily feel it is airborne. And it's around that compassion bit really and saying, I do believe your child had a reaction, but your theory on the mechanism might be different to my theory. That doesn't mean it didn't happen, but it's about the science within it. Because actually, if you can get that right and the explanation, it can take quite a lot of fear away.

Dr Rupy: Yeah, yeah. I can tell you're having a lot of these conversations in clinic.

Dr Helen: Yeah, I have these conversations all day long. and a lot online with people and, you know, people get quite, um, stressed and upset about the conversations because it's how, you know, when you're trying to do a piece on socials, a snippet of a video or a it doesn't tell you all the facts of the story. That's why if someone asks me a question, I'm always like quite long-winded because you need to know the context to be able to interpret it so that we don't upset you. Um, you know, and I've lived with those allergies myself, but we travelled a lot and we didn't ask people to be nut and milk free for Ethan. We just took our own precautions around that. So took our own food on board. Um, and actually times he had reactions were times where we were in restaurants and didn't check properly. Um, and you know, there's a lot of human error that comes into it. And we are only human. I'd love to say it's completely avoidable, but it's not.

Dr Rupy: Yeah, yeah. Um, going back to this, this broader question of, um, allergies and intolerance on the rise, is this both in children and adults that we're we're witnessing this?

Dr Helen: Yeah, I think we are and I think we will see it more as the children that we've measured carry on. And, a lot of theories around why it's persisting and becoming and I think part of that is we just have too few specialists within the UK. Um, so in terms of like allergy consultants, for instance, there there's barely any of them and I just don't believe that's going to massively change in the numbers because and I went to a fascinating health economics study at the allergy conference where the chap was showing us our data of like baby booms and stuff and basically we're about to hit a massive crisis in the UK because we're going to have a huge peak in the elderly population of kind of 80, 90. And that means we need more orthopedic surgeons for when you break your hip, more people in A&E and more GPs. And when you look and you you sit objectively and look at thinking, I have elderly family members and, you know, I'm a person aware if you had a pot of money where would you put it, you can understand actually, you do need to put it into the services, the social care that that are going to need it more. And that's why they were basically saying not a hope really that you're going to get more allergists. Therefore, I think you need more GPs training and specialising and understanding it more and just a better general level of knowledge. But my point of that is the fact that you often don't get to see a specialist. Paul Turner's data showed that 90% of people staggeringly with an allergy never see a specialist. Really? So there's A, misdiagnosis, so you're probably not even allergic anyway and there's lots of data showing that. And, um, B, you're not getting those timely interventions so that if for instance you've got a milk and an egg ladder, we really know that it's crucial to get at least baked milk or eggs, so you cook it in a wheat matrix and it breaks the protein down into the diet, preferably before the age of one and you'll have a great chance of outgrowing it. I think the reason we're seeing persisting severe milk allergy is you're not getting that timely advice and support and the support you need in between clinic appointments so that when you're trying to navigate putting milk in the diet and you see this, what does it mean? Do you stop? And, you know, we have an online support group set up specifically for that because otherwise what happens is your appointment is either yearly or two yearly or three yearly or never and you don't make any progress. And now you're a a 15-year-old with severe milk allergy reacting to literally a drop of milk and that's never going to go.

Dr Rupy: I want to talk a bit about the ladders a little bit later, but that's a it's a really good point about the gap in treatment and that sort of opportunity to to train the immune system at a young age. And there is a, uh, I think a misunderstanding amongst the public that you can't develop allergies later on in life as well during adulthood. Are we seeing more of those as well? So, suddenly you've been eating chickpeas your whole life or you haven't had an issue with a particular allergen, maybe milk, dairy, um, and then suddenly you start developing signs and symptoms of an allergy.

Dr Helen: Yeah, you can develop it. I don't know the specific data of whether we're seeing more of it. Okay. Um, we do see it. Um, again, I if I think about the adults that I sort of pick up, sometimes it's an adult within the child consultation that will say, oh I also react to this. And if I've got a spare 10 minutes, I'll say, 'Oh, tell me a bit more about that'. Sometimes it isn't allergy and I was doing, you know, for a lady the other day and we did testing and it was all negative. And I'm not quite sure what the process is going on for her yet is, but I think there's a big proportion of people out there who think that they have developed an allergy and something else went on. And that does matter because you're walking around fearful and you might not need to be. But there is also the adults who will develop allergies for the first time. Generally speaking, there'll be some sort of background of atopy. So, like perhaps they had eczema when they were younger or they've got environmental allergies and now that food that was always fine is not anymore. It's quite unusual with no background of allergy to just suddenly have a new allergy say in your 50s, not impossible, but less likely. I guess the only difference from that though is that any of us can be allergic to bee or wasps or medicines at any point in our life. So we're not allergic to medicines or bee or wasp stings the very first time we're exposed. So if you're think you're penicillin allergic because you reacted the very first time you'd ever had it, you can pretty much guarantee you're not because your immune system wouldn't recognise it. So for any of us, and it's not linked to the other allergic conditions, if you've been stung by a bee, the next time you're stung, that might be the time you have an allergic reaction. And that can happen at any point. Okay. But the older and older you get, your immune system isn't quite as reactive, so we do see less allergies in like the 70s, 80s, you wouldn't expect new allergies to suddenly form to them. I think we do get a lot more drug intolerances probably different mechanisms. But yeah, lots of people come to see me thinking they've got hay fever or some sort of environmental allergy particularly if they've got eye symptoms in their 70s and they've got no background of allergic disease and I'm already thinking it's probably not and it's not, it'll be linked to your medicines, dry eye, all sorts of other conditions. But you need the right support and diagnosis in order to target the treatment correctly. Otherwise, taking an antihistamine is going to be pointless.

Dr Rupy: Yeah, yeah. And I guess it goes part and parcel with this concept of immunosenescence. So this your your immune system gradually becoming less robust as you get older. But I guess that's quite a lot older. Yeah. Um, earlier on, we're exposed to a whole bunch of different things, change in diets, I mean, lots of us don't eat enough fibre. Our gut microbita is generally declining as well. Yeah. And then obviously you have the hormone shifts associated with menopause. Are these sort of triggers that could potentially tip someone over into having a true allergy?

Dr Helen: Yeah, we do see changes around particularly hormonal times. Um, but I think what's quite interesting is that for some people, it makes allergies better and some people it makes it worse.

Dr Rupy: Oh, interesting.

Dr Helen: So like in pregnancy, for instance, you know, some people say, 'Oh my eczema disappeared' or, um, 'my hay fever was much better'. And the other person is saying, 'Oh, mine was so much worse' or 'since I've been pregnant, I've had this problem'. Same with the menopause, sometimes people will say, 'Oh, I'm so much better' and other people are saying, 'Oh, I'm so much worse'.

Dr Rupy: So what the whole?

Dr Helen: No, it doesn't make no sense, does it? So, um, but I I see both ends of the spectrum, either they're better or they were worse.

Dr Rupy: And do do we have any explanation as to why?

Dr Helen: I don't think we do. No. And it's gosh, it's so frustrating. It's so frustrating. It's so frustrating. So it's like, oh, I don't I don't know. Um, why it's different. You know, we have to just help you with managing what you now have, but why it happens, I don't know. A controversial topic to bring up, but I also see similar around COVID. Um, and so I often see people say, I really think the COVID vaccination caused me all these skin rashes, these allergies, etc. The reality is, it possibly did, but COVID itself also does it. Yeah. And so when you're balancing off, you know, the vaccination is life-saving, in my opinion, I know that's controversial. Um, yes, it might have caused you worsening eczema or new eczema or whatever the symptoms are, but I also see that happening just purely from having COVID. Right. And obviously as a GP working in that time, I also saw a lot of death, so. Um, but it's really, that's really difficult. And again, it's that kind of where's that virus involved in the immune system for triggering these things?

Dr Rupy: For one thing we still don't know about to another. Uh, I I've always wondered why particular ingredients, at least in the UK, are commonly involved in allergies. Shellfish, dairy, like we've mentioned, gluten, egg, why is it peas or legumes? Why is it these, uh, particular ingredients? What is it about them? Because they're they're not structurally similar or.

Dr Helen: No, they're not related. I mean, there is an element of it's what we eat and what we are surrounded by is what we're more likely to be allergic to. So you've got the top 14, interestingly, not lots some of those foods that are on the top 14, I would say are not things I see that commonly. So I do see them, but not necessarily that commonly. I think it's fascinating the shift in newer allergens we're seeing. So you mentioned legumes, so peas and lentils and chickpeas. But actually, if I go back to when I first started practicing allergies about 10 years ago, the children I would tend to see with allergies to those sorts of things were often Asian children with terrible eczema. Is that because that's what they ate more in their diet than, you know, a white Caucasian may have eaten? Whereas now the amount of pea and lentil and chickpea allergy I'm seeing is staggering. Um, and so I I feel arguably it's definitely creeping up there with one of the top allergens I'm certainly seeing and I know other allergist have commented. And my colleague who works in Scotland said on the I think it's the Western Isles of Scotland, the amount of lentil, chickpea, pea allergy they're having is huge. Really? Um, I I hypothesise that a lot of it is around the fact that when we have been looking for like gluten-free alternatives for instance, particularly with the shift of health drivers saying like wheat and gluten is bad for you, you must have different proteins. Well, you have to then replace that in bread, don't you with a different flower product. And, you know, traditionally we would use soya or you'd use gluten. And now what if you look at the breads, you'll find chickpea flour being used, lentil flour being used. And I just personally think we were not exposed to that before. Wow. in the quantity and that's why we're seeing more of that allergy forming.

Dr Rupy: That's so interesting. I mean, do we see, I mean, looking, whenever I think of, uh, legumes, like lentils and chickpeas and that kind of stuff, I think of my traditional diet, uh, Indian diet. Do we see more of those allergens in, uh, typical Indian population exposed to more of those proteins?

Dr Helen: Yeah, it would be the allergens that I would classically see in those families. That's why I say like if you went back years, they would be what, you know, they would have more of that and then perhaps like a white Caucasian would have, um, milk and egg and, you know, maybe a bit of peanut, but not not the legume stuff, not as much. So, I mean, that's only my one observation. But, you know, yes, I worked in a tertiary service. It would be a very unusual clinic where the white child would have all the legume allergies, whereas now it's almost standard. And I've got children who are allergic to like 20, 30 different foods. And I mentioned before, you know, in if I think about rice allergy for instance, I could almost sit here and say to you, if you said to me, I think I've got a rice allergy, I could probably say without testing, doubt you have. Whereas in Japan, it's really common. And obviously, it's not that we don't eat it in the UK though. So I don't quite know that, but you will have differences in what are the main allergens depending on the country that you live in. And some of that probably comes around to the exposure of food to the body and why we think that allergies form. So we know that you are much more likely to have food allergies if you have eczema. It does not cause your eczema, that's a big myth. But we know that if you have eczema, your skin barrier is not the same as someone else's. So it's leaky, it can't waterproof itself, and it means that allergens, foods can cross into the skin barrier. Okay. So, although I said if you're allergic to bees, for instance, you can't be allergic the first time you're stung, you can be allergic to peanut the first time you eat it. And that's because it crosses over your skin barrier. You're showing it to the immune system in a weird way, like here it is over the skin. So now it's saying, 'Well, this is foreign and I'm going to treat it differently'. And it sets up an immune response. So then the first time you eat it, you react. Whereas other people who maybe don't have eczema, it might not be that first exposure. The classic time would be the third exposure when your immune system starts going, 'Oh, hang on, I don't like it'. But having eczema, particularly poorly controlled, puts you at risk of gathering multiple allergies. And what's quite interesting, so I had a Sikh family who didn't eat egg at all because, you know, they're not not able to. And their little boy had multiple allergies. The one thing he always tested negative to was egg. And yet with his terrible eczema, you'd have thought we know that children with eczema have higher risk of egg and peanut allergies. But he didn't. And I suspect it's because they always had strict avoidance and never went anywhere near egg. And I do see that. You hear this classic story of, 'Oh, you know, mum', and it's terrible because we beat ourselves up so much as mums, but mum saying, 'Oh, but you know, cashews were the nuts I loved'. And now my child's allergic. And you're a bit like, it's probably because you were eating them. Now, it's not to say don't, because, you know, you've got to eat. Um, but it probably crossed over your child's skin barrier and that's why they happened to be allergic to that nut.

Dr Rupy: Gosh, that's going to be so worrying for so many parents.

Dr Helen: It's so worrying because they literally, the amount of guilt that, so I I work with a clinical psychologist who specialises in food allergies, Francesca Soy. And when I I started this online membership where people could pay a subscription, they come and um, they have a short one to one with me and the point was there was an allergy community online and they could ask me questions every day and I support them through that missing gap of their appointments. So as I started doing it, I quickly started going, hmm, I don't know the questions about your ladder. How much protein is in that food? I'm not a dietitian. So then I was called upon my allergy dietitian to say, 'Come in the membership'. Then I called upon a who's a specialist dermatology nurse, 'Come and help me'. And then I was like, oh, the mental health challenges that families are facing and the impact of allergies, I was like, Francesca, you've got to help me. And so she's in there supporting families through, um, and is fully booked for all her one-to-ones because it's the burden of living with allergies, the guilt, I you know, I think people do feel in any chronic disease for their children. I think you just start blaming yourself. But particularly with eczema and allergies, parents think it was all their fault. And it really isn't. It just, it's not. It is genetics. But I reflect, you know, and I think I can say this because I've had children with allergies or have children and say like, I sort of say to my children, 'Well, what are you going to do? You're going to be born or you're not? This is the genetic mix that you got. Yes, it happened that our genetic mix meant our children had allergies, but for another family, it means they've got diabetes or they've got thyroid disease. You can't feel guilty about that. You just can't, we can't, you know, guilt has to have a purpose and something you could change and you can't change your genetics. So there's no place for it. So I think people are too mean to themselves.

Dr Rupy: Absolutely. Your clinic sounds, um, incredible with all the different disciplines that you've collected there. Um, if someone was to, uh, come to your clinic, um, and let's say, you know, I'm I'm coming, I've got some dry skin, I've got some bloating, I've done some googling or chat GPTing, and I think I'm allergic to, I don't know, uh, peas or, uh, a certain type of nut. How would you structure the clinic appointment in terms of, you know, what things would you ask me my history, how would you, how might you investigate it and unpack all the different things to come to, uh, a solution?

Dr Helen: Yeah, so there are three of us that work because I've been, um, gathering colleagues. So three allergists or GPs that are interested and then a dermatology specialist nurse. So we would, I so the way I would approach it when people particularly maybe adults, young adults looking at their gut symptoms is I start right back at the beginning, which sounds a bit weird. So if you happen to bring your parent with you, which actually often people do, it's actually quite helpful. So I want to know like what was your birth history? Um, do you know whether you had formula feeding or, um, breastfeeding? Did you have early antibiotic exposure in life? Because those things might increase your risk of allergies forming the, you know, that's part and parcel of it.

Dr Rupy: Is that all because of the impact on the gut?

Dr Helen: We think it's the gut. Yeah, with the vaginal delivery versus cesarean. Now, these are all reasons people start feeling guilty. And I always go, not allowed. Just it is what it is, you know. Um, and also what's your family history? So what's mum, dad's, siblings' history of have they got allergic disease? So I'm already staggering stacking up then where's my likelihood of pitching allergy here or not. Then I want to know in those early months pre-weaning, what sort of baby were you? Were you a baby that was really unhappy? Do you know often, I I will tell my middle daughter because I think she had a milk allergy that I just didn't realise that she was a screaming horrible mess and not very fun to be around for a year of her life. I think you do hear those conversations. Um, I remember my mom saying, 'Oh, you were always so spotty'. And I think that what she was referring to was that I had eczema because then I had an egg allergy and asthma and um, and so you hear that. So what were your bowels like as a baby? Did you have any growth issues? What was your skin like? If there was none of that, that's fine, but I'm just parking that whether I think that these delayed non-IgE allergies might have a role for you. Um, then going into early childhood and weaning, did you start to have bowel issues? Were you constipated? Looking at family history of gut disorders. So is there any history of Crohn's disease, Celiac disease, any other autoimmune conditions? So I'm weighing up is it allergy, is it intolerance, is it another condition that we're missing? So then we try to look at when did these things happen?

Dr Rupy: Just to pause on the, um, uh, infant, uh, journey. just yeah, infant journey because uh, I've got to say to my seven month old. And uh, we recently actually went through the process because he he had some issues and was crying quite a bit and all the rest of it. He's currently on, uh, goat's milk, which he's thriving on really, really well. Um, so we didn't have to go completely, um, uh, dairy free or lactose free. Um, a lot of parents might be listening to this and like, oh, I think that's my child or some of these symptoms that you mentioned a little bit earlier in terms of, um, irritability, eczema, etc. Um, it can be quite hard to have that conversation with a general practitioner, as you've alluded to, who doesn't understand the allergy process and what actually might be triggering it. Yeah. Are there quick ways in which we can determine whether there is a true allergy, uh, involved in, in the symptoms that they're, they're experiencing?

Dr Helen: Well, there's no test for this non-IgE. I would love somebody to develop a scanner where I could go and IgE, non-IgE or, you know, infection, um, what we used to call functional gastrointestinal disorders, which are now disorders of gut brain interaction, which to the lay public is things like colic, sometimes babies have diarrhoea or constipation that's not linked. So there isn't, the way we would diagnose these delayed allergies is you remove it from the diet for two to four weeks, see if things get better, and then we upset you all by saying, please retry it. Um, now I will say, it isn't that, you know, we wouldn't say retry it for two weeks. It's just if you're, for instance, if you're formula feeding, try an ounce in the first bottle of the day. If you were breastfeeding, sometimes I'll say to mums, have a latte, or actually what I usually say is, eat something you really want to eat, and then don't eat anymore. Then wait 72 hours because these symptoms take two to 72 hours to show up. Then if nothing happens, gradually increase it because sometimes it was just a developmental thing and it's settled. And in fact, more often than not, that's the case. Um, or sometimes it's almost like it just needed a reset. A bit like with irritable bowel syndrome, some people follow the FODMAP diet where you remove quite a lot of food groups. It isn't designed that you do that forever. You do put them back in and there is a relative tolerance level. And if you don't do that, because people go, 'I'm fine, thanks, my baby's sleeping', and we all know that's important. Um, what will happen is you can end up with a misdiagnosis, you start following this path that brings you worry, does unfortunately mean you get exclusion in some settings because now your child can't eat at the parties and cost because, you know, free from foods cost a fortune, but also particularly if your child has eczema, and this is why I get driven mad by people saying do elimination diets to see the cause of eczema. Removing food from the diet when you've got eczema can actually lead to complete loss of tolerance and then an IgE mediated allergy forms with anaphylactic risk. And I've seen that a lot. And no one has ever said to me when that's been the case, I'm so glad I removed this food from my diet for years on the poor advice of X, Y and Z and now I can't have it because it's put me at life-threatening risk. Oh, wow. So removing it that short and it has happened with adults as well. Gosh. And I've seen it a lot. And we all have, particularly around the bigger food groups like milk and egg and and wheat and the big groups, you need to kind of keep them in. So what's useful for GPs is do a right, we are human beings and right now it's very stressful being a GP. You're talking about 60 to 70 patient contacts a day. It's absolutely ridiculous. I when I do a day of locum and I don't very much anymore, I literally cry. It's so horrid because we actually really, really care about you and we love our jobs and it's been destroyed. So trying to take a full consultation in 10 minutes when the topic is splitting from one to another to another, build the rapport, try and help you, look engaged. I'm hungry, I need a wee and I've got my cup of tea. You know, we are human. So make it easy for us. So do bullet points. Um, take a photographs and put them in a photograph album and show us what you want. If you've got some useful stuff from Allergy UK or Anaphylaxis UK, bring it with you. I know you want to feel heard and to share more of the story. But the reality in 10 minutes is that's very hard. And we want your key points, your top line things rather than, 'oh and then I went to the cafe and I was upset'. I I've got time for that in my private clinic and I'm all here for the stories, but in GP, you've got a point that you want to get across. You don't want to spend 10 minutes talking and then they haven't got time to explain it to you. So make it easy for them, explain what you think and what you've heard. And if you don't get the support you think you need, ask at the desk, who is the GP in the surgery who's really good at allergy, dermatology, heart disease, whatever you need to see. I always say don't come and see me about legs because I had glandular fever at university when the leg modules were on, I'm not good at that. So, you know, we do have different things we're good at. Um, and also, you know, because as a GP, we're quite privileged in that we see things at the start of a journey. Sometimes people say to me, oh, you know, it was so obvious from the beginning, but actually we need that time to see are other symptoms creeping in that now make us think this is allergy or actually is it closing the door? You know, you always hear about the bad things GPs did, but you don't hear about the millions of people we've helped, you know? So, it's trying to be fair because we I honestly, I'm on lots of groups. I've got lots of colleagues. It's unusual to meet a doctor that really doesn't care about you. They really do. They go home, they have lots of sleepless nights, they stress about it. It's pretty hard, miserable job at times because we're we're carrying a lot of weight of responsibility.

Dr Rupy: Absolutely, yeah. My job is so much easier now with an hour consult.

Dr Helen: Yeah.

Dr Rupy: I'm going to bring you back to your your perfect clinic at the moment. So we've gone through antecedents, you've asked them about birthing history, parents history, infancy, all that kind of stuff.

Dr Helen: So yeah, so then I'm trying to weigh up like when did your symptoms come in? Have they have they always been there or is this a new condition? What things have you tried already? Have you tried dietary exclusions? Obviously always thinking in the back of my brain is there another diagnosis that is unifying? Do I need to do some bloods to make sure this isn't Celiac disease or um inflammatory?

Dr Rupy: which is a great position to be in given you're a general practitioner so you can, you know, zoom out from the allergy lens and actually assess is this thyroid, is this hormone imbalance, is this menopause, it could be a whole bunch of other things.

Dr Helen: It could and I I do genuinely believe I said earlier, that's why I think as a GP, we make really good specialists because we come into it with a really general, um, level of training, which means that as I say, don't ask me too much in depth about another topic, but I'm really good at allergy, but I'm also really good at that overview to go, oh yeah, I remember, like we need to be thinking about X, Y and Z. And now maybe I've made a diagnosis of Celiac disease this week. Now that's not my specialist interest, so I've said to him, I think it's likely you've got Celiac disease. Now I need to get a gastroenterologist to help you further. So I'm assessing is there anything else I'm missing to pull that picture together? Stress is a huge thing that people overlook and there are so many links with our brain, with our gut, with the immune system, that goes back to sometimes people have made these patterns of it being food and what I sometimes go through is like, if you've made all these eliminations and nothing's getting better, perhaps it really isn't that food is the answer. And sometimes we're left in a position of going, I don't know what the answer is. And sometimes we have really long challenging conversations about how can we help you learn to live with the state you're now in. I see a lot of people who spent thousands of pounds on so many appointments, professors, specialist things and they've still not got answers. And sometimes they come to me as now is it allergy? And I'm going, it's not allergy. This is not the missing piece. Somebody would have thought about this beforehand. So I actually what I do is go, I don't want you to spend any more money. I have a real problem with people wasting money. And if you come to my clinic, more often than not, I'm talking you out of allergy tests. I mean, we should have a shared decision. Um, and you know, I've had a few conversations this week of, I think this might be your health now and I we don't know why until maybe something new evolves, but how can you live well on the good days and on the bad days accept that this is perhaps where you're at. And that's hard sometimes to do. So it is sometimes helping people piece the puzzle together of actually have you put two and two together and made five and the food is not related. And then is it not much nicer to go and have a nice meal and a glass of wine than be cutting everything, still miserable and still not getting the answers you need. Yeah. Sometimes though, we've worked out that's actually was a non-IgE allergy to milk that was there since childhood and restricting and reducing it slightly. I've had so many emails of oh my, you know, my I'm a completely different person.

Dr Rupy: That's incredible. but it's pulling the whole story together and making sure we've done appropriate tests and not excessive.

Dr Helen: Okay.

Dr Rupy: So you so this all comes from a detailed medical history, symptom diary, etc. Do do you do food diaries? Are there like uh.

Dr Helen: I don't really. It's funny, isn't it? Because sometimes when I work with charities, they're like, and do a food diary and I'm like, oh.

Dr Rupy: Really? I.

Dr Helen: I'm not a huge fan of food diaries. Um, I have a few circumstances where I do them, but not often. So certainly if we're talking about immediate allergy. So if you're somebody who's talking about getting hives all the time, I don't need you to do a food diary because if you can't tell me every time I eat milk, I get hives, you've probably got spontaneous urticaria where this is urticaria is just a fancy name for hives. It just means it's happening because your body is just releasing histamine and not linked in because when you get just for the listener, so hives are these weals like.

Dr Helen: They're raised bumps. They look slightly pale in the middle and red around the side. So they do look like a nettle sting and they really itch on the whole. And they should go away without leaving any marks. And if they leave bruising, then we would worry about that from other diagnoses. And it's common for about 10% of people in their lifetime to have hives unrelated to allergy. So when people, you know, say, is this an allergy rash online? That always drives me crazy because I'm like, what's the history? I need to know the story. because COVID in about 25% of people can trigger hives and sometimes that's it. Viruses really commonly trigger hives. Um, stress definitely triggers hives. Fascinating study showing that in people where they were trying to delabel them against penicillin allergy, the first dose they gave people was placebo, so not the drug, and 25% of people got hives. Wow. Because of that link of your brain into your immune system that can cause histamine release.

Dr Rupy: Wow.

Dr Helen: And that goes back to the aeroplane situation that when you're on an aeroplane and you thought you had an allergic reaction, did you or and this is not trying to say I don't, you know, you've got to it's just trying to say what was the mechanism? Or did you get on that aeroplane already thinking, I'm really stressed here and this person across there has got nuts or someone was rude about, you know, all of those factors that go on. Um, and you've got your previous memory of what allergy felt like, etc. And now you get hives, were you really reacting or was your was your brain telling your immune system I'm in danger.

Dr Rupy: Yeah.

Dr Helen: And that's so hard to.

Dr Rupy: And the outcome is the same.

Dr Helen: And the outcome is the same, treat it the same.

Dr Rupy: But it's just a different.

Dr Helen: It's a different. You still say you can take your antihistamines, you're going to use your adrenaline appropriately. But it's understanding that and, um, you know, fascinatingly when people get spontaneous anaphylaxis, so anaphylaxis that occurs without a trigger, often that's a very stressful place to be in because you can't control it. Um, I've seen that a lot in young teens that they start having multiple episodes when they work with a psychologist, it comes under control. Because if you start and it's it's a vicious circle, of course you're going to feel stressed all the time, but having more support around it can reduce the amount it's happening.

Dr Rupy: Isn't that crazy? Because I don't think we've fully, um, unpacked exactly what anaphylaxis is for the listener, but, um, maybe I'll ask you to you probably explain it all day long. So, how would you explain anaphylaxis to a lay person?

Dr Helen: Well, you see, anaphylaxis is not that easy to explain in a way because it depends on what country you're sitting in. Okay. So, um, and I think that goes to like part of the great things and the worst things about social media because I watch a lot of American allergists online and they're always like, use your epi. And I'm like, no, we wouldn't use our adrenaline in that circumstance. So they use it differently. So broadly, it's a severe life-threatening reaction, you know, that involves the whole systems of the body. And in the UK, we would define that mainly as ABC symptoms. So airway breathing, conscious or circulation. So persistent coughing, so it sounds like you're clearing your throat. tongue swelling, your voice going croaky or absent, breathing problems, so wheezing, dropping your oxygen level, dizzy, um, feeling faint, floppy, collapsed, of course. And there are a few other bits. So chest pain associated with it can happen, profuse vomiting. Whereas in in America, they say if you have two system involvement, so hives and a vomit for instance, they would say that's anaphylaxis.

Dr Rupy: Oh, I didn't realise that.

Dr Helen: Yeah. And so I think what that should reassure listeners about is they use their adrenaline much more readily. Yeah. It's fine and safe to do so. Are their outcomes different? No. And so I reflect on my own son's situation. He did have anaphylaxis a few times, but there were multiple times he had vomit and hives because milk particularly, he's 16 now. 16 years ago was there was very poor food labeling and we had a lot of accidental exposure. He would have had an epi pen a lot and it wouldn't have changed his outcome. And eight out of 10 episodes of anaphylaxis resolve without the need for adrenaline. I'm not saying risk it. Of course, use it. Um, but we do produce our own adrenaline when we're stressed. So people have so many myths around anaphylaxis of your reaction gets worse every time you eat the food, the next time is going to be severe. It doesn't help that you go to A&E and some soul says to you, 'Oh, a minute later and you'd have died'. And I'm actually going, probably that's actually really unlikely because I do think deaths are underestimated because there's probably difficulties in misdiagnosis of anaphylactic death versus asthma or what was it? But roughly speaking, there are 10 deaths from food allergy a year with another one or two people on intensive care a month. So whilst that's too many, it isn't the numbers that sometimes people think.

Dr Rupy: Yeah, yeah, yeah, I think that people would vastly overestimate that number per year.

Dr Helen: Yeah.

Dr Rupy: So, um, spontaneous my point was spontaneous anaphylaxis, uh, it sounds incredible that the body can produce this Yeah. outside of a an external trigger. So you're literally developing anaphylaxis as a result of a psychologically induced mechanism.

Dr Helen: Well, there's some links with it. I don't think it's all down to the brain. So for instance, it doesn't just suddenly happen because you're stressed. But what happens is you might have anaphylaxis and then of course you go through this, what is it? And then you might go for testing and then we might say to you, well I don't actually think this was a trigger. Okay. Um, and now I don't we don't know why it's happening to you. And of course that sets up worry. So what we see is for those people whilst there's that element, some some of them, you get like clusters then of more and more anaphylaxis episodes happening and when they work with a psychologist, it can reduce it. Doesn't stop it because it's not the whole mechanism.

Dr Rupy: Sure.

Dr Helen: So I wouldn't want people to think it's only because of stress, but there's a link in with stress, but we know that with everything, anything where you're stressed, all chronic, all illnesses, you know, diabetes, asthma, everything will be worse when you're stressed. Um, but why anaphylaxis happens spontaneously or why you get random hives?

Dr Rupy: are there scenarios where anaphylaxis is more likely to happen outside of perhaps, you know, you stress was a a pre-existing symptom you had or?

Dr Helen: Um, you mean spontaneous ones?

Dr Rupy: Yeah. Or any co-factors with.

Dr Helen: Well, I mean, yeah, co-factors are an interesting one. So it's funny really, the more you learn, the more you don't know. Um, so for so long and I still do talk about co-factors and I describe it as the perfect storm. So, you know, we think that you are more likely to have a more severe reaction if a co-factor is present when you eat the food you're allergic to or you're stung or whatever. And those things are if your body's ill, so you're already fighting something and then you eat lots of what you're allergic to, you'll be more likely to have a severe reaction. We know that if you've got asthma, if it's badly controlled, that puts you at risk. We know if you've run around and exercise just before or after, if you're exposed to heat or cold, if you are fasting, if you're around your period, if you're fatigued, if you've had alcohol, all of those things can trigger worsening reactions. Although there are there is a study showing that exercise as a co-factor is perhaps not as important as we think. And um so that's why I say the more we learn, the more we don't know. Yeah, yeah. Um, but at the moment we do talk about sometimes when you look at the really difficult circumstances of somebody having died, there's often multiple things that kind of went wrong. Um, I think of a few lately of like, you know, young teens, young adults on holiday for instance, I think one stuck in my mind where he went and had a cocktail and I think the milk got mixed up in the cocktail because actually sometimes, you know, you think you go for a drink and you don't actually think about the importance of declaring your food allergy when you're having a drink, do you? But, um, you know, is there food around? Are we now using more nut milks for instance or or even some oat milks have pea in it and so you do actually when you go to the coffee shop or out to a bar, you need to declare your food allergy and we should be asking a lot more. Anyway, his milk was mixed up, he had anaphylaxis, of course, he was out dancing, had forgot his epi-pens. And then in the reports I read, ran back to his room. And we know that one of the worst things you can do when you're having anaphylaxis is move around and it will potentially progress your reaction, drop your blood pressure. And all of that was the perfect storm and he died. So, you know, it's every parents' absolute worst nightmare. So when people are coming to me for treatment, it's because of that exact scenario because that is human life scenario. You know, do we all carry adrenaline auto-injectors when we should? No. And there's an argument of, you know, sometimes when severe reactions happen, they might happen regardless of whether you give adrenaline. So it's not a right or a wrong situation actually. Um, and we just can't always avoid it. And it's just it is your worst nightmare as a parent.

Dr Rupy: Yeah, yeah. Um, okay, so we're back in your clinic. Uh, so we've got the detailed medical history, not necessarily a food diary, it sounds. No. But people might have brought them, but usually when people bring them, they say to me, I can't find any patterns.

Dr Rupy: Okay.

Dr Helen: And that's important to me.

Dr Rupy: That that's an important finding I guess the fact that they they haven't found a pattern themselves. Doesn't sound like you're a fan of elimination diets or you would you remove certain triggers if you had a hunch that it might be a particular food.

Dr Helen: Yeah, so I'm looking at what is the most likely. So for instance if I'm looking at young children and the non-IgE, the commonest things is cow's milk. And you mentioned about the goat's milk. And actually most animal milks have got the same sort of protein structure as cow's milk. So if you were truly allergic to cow's milk, and I tested that theory with my son, he would not manage goat's milk. So he vomited everywhere, had hives and his consultant said, why did you do that? They're almost identical proteins. I was like, how would I know? I mean, I think the level of of knowledge we're expected to have about food. Um, you know, if your listeners probably do have more knowledge than I had, but I certainly didn't know that. So interestingly, the only animal milk that's not really similar is camel milk, but please don't go and drink it because it carries other diseases. But yeah, so you could have camel milk. Oh really? Oh wow. Oh gosh. A complete detour, isn't it? So I'd think cow's milk and then some children with delayed allergies are more likely to have soya. So I might think of soya with that. Then I think of egg and wheat and those are my commonest things. Now, if you're a breastfeeding mom and you're looking at triggers, if you start removing all the legumes and now you're taking nuts and you're taking seeds, I really am strongly thinking you are barking up the wrong tree in that maybe there is allergy as part of the component, but sometimes these babies have a very sensitive gut and it's a really difficult journey actually, but they don't get a full resolution of their symptoms. And I think what happens is people, adults and, you know, parents for their children get into a state of I've took one thing out. Did it or I'm not sure if it made a difference. And then like fear of putting it back. So they think, well maybe I also need to take X, Y and Z out and perhaps it was the cumulative effect of taking all of those things out that made me better when really I'd go, look, if it's not made the difference, put it back. Then if you're going to try something else out, fine. But it's unlikely you're going to need 20 foods out of your diet. And besides that risk we talked about of complete loss of tolerance, which is probably only relevant if you've got eczema. It's the fact that you're losing all those nutrients and that will impact on your growth. And it's fear. I have so many adults with just sheer fear of what can I eat? And whether that's life threatening reactions or not, nobody wants to feel unwell. And now they're just really nervous about eating anything again. So it you know, these people really need a lot of support.

Dr Rupy: Going back to my scenario with the with the cow's milk and the and the goat's milk. Even in the absence of a true allergy because the protein, like you said, is the same. Could there be a difference in taking goat's milk versus cow's milk because of the quantity of the lactose or the different type of protein?

Dr Helen: I think it's probably the lactose and maybe that so I do always, not always, I have found a lot of families who say that their children seem much better with goat's milk from a gut perspective and sometimes reflux perspective. And it might be the lactose difference in it, or there might be that slight protein difference in it, but that slight protein difference isn't big enough to change it if you had a milk allergy, you're going to react. Of course. But yeah, it's really common that if we've got more of these functional gastrointestinal disorders, goat's milk might be a better alternative for families to try.

Dr Rupy: There there is also a bit of a trend, sort of going down a bit of a side quest here, uh, for A2 milks, like Jersey cow milks and that specific protein. Um, are those better for certain people or is it just try and then see whether it works better for you or not?

Dr Helen: Are they milks that they would like shop-bought milks?

Dr Rupy: Yeah, shop-bought milks, yeah. None of the raw milk stuff.

Dr Helen: Yeah, I don't do the raw milks. Um, I can't think really of circumstances where they're necessarily going to be better because you're looking at the protein and which ones might be triggering a reaction, then I'm looking at the lactose and if that's relevant for you or your child. Um, so I don't see why Jersey milk people are jersey get upset. milk is necessarily going to be different from other cow's milk. Um, there might be some health component I'm missing but not from a medical perspective. It's not usually something I think of.

Dr Rupy: Okay, okay. Um, Dr Helen, you haven't given me a test. I want a test. How do you feel about tests, skin prick testing, IgE? Let's unpack all this.

Dr Helen: Yeah. Oh dear. There are I one of the worst conversation or I have so many difficult conversations, but it's really hard when people ring my secretary or they email through to us and they say, I've done the X test. common brands. Um, I spent a fortune, hundreds of pounds. Will you help me analyze them? They've told me all of this stuff. And then I say they're not accurate. And even when there is a particular brand of companies who do an IgG and they do the IgE component with it and their IgE, which is the test you would do for allergy, the immediate allergies, do not ever match up with our NHS testing, my IgE testing, skin prick testing. I don't know the validity of their lab. Oh wow. But it's just not accurate and so it might as well just put it in the bin.

Dr Rupy: Wow, really?

Dr Helen: It's so hard. People always say, would you like to see? And I'm like, it's just not even worth the paper it's written on.

Dr Rupy: Oh my gosh, that's crazy.

Dr Helen: So it's really hard. I really strongly feel they should be shut down.

Dr Rupy: So so just to just to refresh for the listener, we we talked about IgE and non-IgE. What where do the IgG tests come into this?

Dr Helen: So IgG is paraded across, you know, you being targeted online because and people often go because they need help. Um, as an intolerance test. If we go back to the very definition of intolerance, reproducible adverse reaction that does not involve the immune system. IgG is the immune cell, immunoglobulin G. So first of all, it makes no sense. Secondly, we can't diagnose all intolerances because I wish we could, it would make my consultations quick and easy and and more helpful maybe. But you just can't because everyone has a different mechanism. And I go back to we don't understand the mechanisms for all. IgG testing actually reflects more of what you've been eating lately. Okay. Um and I've got a a a person who reached out um who I've had lots of chats with and I think she's writing a book around it. And so she did I use a, it is a home test kit you can buy, although I put um some kind of caveats and rules around who can order it. Okay. And it's an IgE test, which is more extensive. So she said, can I do that? So she did and she used this popular company to check the intolerance testing. And she went out and ate, I think she said something like a 15 course meal the day before and it just flagged all of that stuff up. And she's I don't have allergies and the IgE testing was completely negative. Um now, why does it matter? Well, because it creates a lot of stress and worry. Um, if this is a child, you're removing that food from, we see a lot of harm come from that from the, you know, the nutrients they're missing their growth, but I go back to if you've got eczema, you are really risking that you're going to lose tolerance to those foods. And then, you know, if you don't get the right support that you need, um, it's going to be unhelpful. I had a lady call me yesterday, she'd done one of these tests, spoke to her GP and the GP said, well, that's the same as the one we would do. And they're right in that it was an IgE test. But I know that particular company is not accurate. And um, so years go by and she's now got multiple foods out. So hopefully we're going to help her unpack what she's actually allergic to. But from hints in the story, I think she's allergic to one food and yet she's got out peanuts, tree nuts, sesame, all the legumes and soya. That's incredibly restrictive.

Dr Rupy: What do people eat when they're on these really restricted diets? I've always like.

Dr Helen: I know it's a real challenge. In fact, one of my lovely, um, people in my membership who's become a friend, that's one of the nice things. They really become your friends. uh, has asked me a question. I'll have to ask you about it. But she said her son's got multiple allergies and they are like lots of the legumes. They're Asian, they're mostly vegetarian. He doesn't eat much dairy. So he doesn't eat legumes, chickpeas, nuts, seeds. So she did say, where can you get the protein content? So that's a question for you to think about. But what's that?

Dr Rupy: I have to look at the full list of allergens.

Dr Helen: I think, um, allergy families find it a little bit frustrating when you sort of say like, what do you eat? What I actually find about many of these families is they become ridiculously amazing at cooking and looking for alternative sources of foods. And that's where like a good dietitian is worth their weight. Um, so you know, for instance, if you're looking for egg replacement, you might use chia seeds to help you bind it. Yeah. Um, and they make a lot of homemade healthier cooking really. Yeah. Um, to keep themselves or their child safe. But it just can become quite life-affecting because we all want to just go to our friend's house or sometimes go out for dinner and, um, and have that treat. And you can't necessarily do that.

Dr Rupy: Yeah, I really resonate with that. I think even the challenge of eating, uh, healthier foods and creating healthy recipes from simple unprocessed ingredients has challenged me as a home cook to develop these recipes that are flavourful and easy, etcetera. And even within the plant-based and vegan community, because they're restricting artificially, you know, eggs and meat and stuff, you find some really incredible hacks, like, you know, egg binding with chia and flax and and and protein replacements with chickpea as long as you're not allergic. Um, so yeah, no, it's it is pretty pretty awesome what can happen from from those restrictions.

Dr Helen: It can be amazing. But sometimes, you know, it's it's frustrating right? I was asked to be a judge for one of the free from competitions a few years ago. And as part of that, we were looking at the backs of the labels. The food that tasted the best had the minimal ingredients. Staggering sometimes what we put in. And, um, sad. Like I do get it, but I think that we don't, and I'm not, and I said to you before, I'm a do as I say, not do as I do person. I do need to be better. But I I do think that we are not good with our diet. And I think it starts from the beginning. And so I think from what I would say to allergy families and parents particularly when they're beating themselves up and they're always looking at, you know, what what else could I do to improve my child's gut microbiome and they put it on themselves. But often these young people are having incredibly amazing diets because their families are home cooking everything from scratch. So you're doing like a phenomenal job that I think will probably keep your child safer from chronic disease from other things. Um, yes, they'll they may well live with their allergies, but they will probably have a better, lower risk of other disease.

Dr Rupy: Yeah. Yeah. So, you're doing some tests. Yeah. but not and which tests are we?

Dr Helen: So, um, if I I will probably try and persuade you not to do testing if I really don't feel that you have that IgE mechanism. But I again, I think it's a shared decision making really because some people and even health professionals said to me like, I know what you're saying, but I sort of need to see it in my mind and then I can move on from it. And on the most part, that's fine. The challenge we sometimes have is you can have falsely positive tests and that's not helpful. But the way I would normally, um, test for immediate allergy would be either a blood test or a skin prick test, which involves, um, using usually solutions, but we can use the real food. So we write numbers on often your forearm so they correlate to something. And for instance if I was doing milk, there's a solution that's got the milk protein in it, put a drop on the skin and you use a little lancet that's got a tiny sharp end just to pop the bubble. So it feels a bit like you've poked yourself with a pencil. So it's not too bad. Babies don't even wake up, so it's not painful. wipe it away, leave it 15 minutes and I'm looking to see whether you've got a raised bump there, measuring it, and then I can weigh up my pre-probability of do I think you've got allergy with the test to give me a diagnosis. The bigger the test does not mean wow, you've got a really serious allergy here, it just confirms what I was probably suspicious of. Okay. because testing doesn't tell us who's at risk because essentially, if you have an immediate allergy, everyone's at risk of anaphylaxis.

Dr Rupy: Okay. Okay. So, skin prick blood. What about, um, oral food challenges?

Dr Helen: Yeah, sometimes I do a food challenge. So, if we just don't know, there's lots of reasons we do a food challenge. Primarily, it's to see have you outgrown what I thought you were allergic to because we had a good story and positive tests. So that's the biggest reason we do it. We might do it where the diagnosis is really unclear. So, um, indeterminate symptoms, it's not, you know, the test maybe is not really strongly positive or not positive at all, but you've given me a story of reacting and I want to see in a safe environment, can the person eat it? Or um, it would be nice if we did more of these. Some people unfortunately go down the path of testing before their child has eaten the food. And if you do that, particularly when they've got eczema, you can have multiple positive tests that are meaningless that do not necessarily mean you're allergic. The problem you end up in is you will see a doctor, particularly within the NHS where capacity is short and who are a bit risk averse, say go, that skin prick is huge. Now, that doesn't mean you're going to have a more severe reaction, but it it means that the probability is you might react. So we go, you probably should just avoid that one then. And by avoiding it, we know that person is more likely to become allergic to it. So it would be better that if you've had screening done before you've eaten the food, that you know, we should really be then doing food challenges to say, are you actually allergic to it? Yes or no, in a safe setting. That doesn't happen and therefore I strongly encourage people not to have testing done before you've eaten it because they're meaningless and it opens a can of worms.

Dr Rupy: Okay. What is a food challenge?

Dr Helen: So what a food challenge is is you come in for half a day, we start with a very small amount of what we're testing, wait 15, 20 minutes, no reaction, bit more, wait 15, 20. And by the end of it, they'll have had a good sized portion that you're probably unlikely to beat, um, in normal day-to-day life and then we ask you to incorporate it in the diet.

Dr Rupy: Okay. Okay. Um, breath test?

Dr Helen: Breath test have a role for lactose intolerance. So lactose intolerance goes to not enough or absent lactase enzyme that's present in our intestines. And so it helps us process the carbohydrate sugar that's present in like milk products for instance. So if you have a milk allergy and you have lactose free milk, you'll still react because it's still got the milk protein in. But if you have a lactose intolerance and you have lactose free, um, milk, you won't have symptoms. There are different types. There's congenital, so you're born with no lactase enzyme, which is pretty much not going to happen in the UK. I mean, you can never say never in medicine, but I haven't ever seen it. There are some populations like in Finland and Japan, I think who have it. And that is a genetic test and those babies would be born very sick, not not gaining weight or thriving and they'd be in hospital. Right. Then you have primary lactase deficiency, which develops tends to come in like your teens and 20s where you can have some of the lactose products, but too much of it and within 30 minutes to a couple of hours, you get bloating, cramping, diarrhoea. Okay. And a breath test then gets you to eat a large amount of the lactose product and measures how much hydrogen, it's called a hydrogen breath test, you breathe out. And from those numbers, we can work out if you've got a lactose intolerance. And then finally a secondary lactose intolerance is where for a period of time, you lose the lactase enzyme but it comes back. So if there's been an insult, and the classic would be a toddler that's got really awful diarrhoea, who's destroyed all their intestine um, enzymes. And for a while, you're saying every time they have milk, they've got hideous diarrhoea. Or you may not have made the pattern, but you're just going to say this child's always got diarrhoea now, but didn't have any early history. go to lactose-free milk and it doesn't happen. And usually after about eight weeks when the healing has happened, it comes back and it's temporary. And that can happen after any insult. So if you've got rip-roaring inflammatory bowel disease, if you've got flares, until it all settles, you might find you have times where you can't tolerate lactose.

Dr Rupy: And this is, just for the audience, that in children and in adults as well. Yeah, okay.

Dr Helen: in adults as well.

Dr Rupy: And are you noticing the increase in prevalence of these as well, primary and secondary?

Dr Helen: No, I don't think so. I mean, obviously, I've always got a slight attention bias because I, you know, people come to me about these things and I see them. Um, and sometimes I just put a label to what somebody knows. So they knew that they couldn't have milk, they don't know why, and I can put a label to it's primary lactose deficiency, um, or intolerance, but I don't think I see it more often.

Dr Rupy: Okay. Um, with the elimination diets that we referred to earlier and how that sensitises you to have a, or you're more likely to have an issue further down the line, the longer you're eliminating them for. Um, what if your elimination diet was, let's say, over eight weeks or 12 weeks, and then you did quite a severe elimination diet getting rid of lots of different products, but then you steadily reintroduced them after, yeah, 12 weeks, let's say. Is that going to still have the same potential negative effects on your tolerance in the future?

Dr Helen: It sort of depends on your background risk of allergy really. So if this is a person who perhaps is older that hasn't got that background of eczema, asthma, environmental allergies, you know, and that's probably a bigger chunk of the population actually who, you know, classically people in their 40s start coming to me saying that they've got gut symptoms that they can't. A lot of I'm allergic to alcohol, and it's not, it's the sulphites and the histamines and maybe another process within it that starts triggering unpleasant symptoms. The likelihood is you could eliminate those foods for a long time and be able to put them back and be fine. If you have eczema, that is my strong warning. And then we don't really know how long it takes. For some people, it's just weeks and you lose your threshold and tolerance to it. Um, so that's why I just strongly believe you should have a good reason for doing something and ideally be directed by someone who knows what they're talking about and one of the biggest reasons we set up our free Facebook group, although it's almost become unmanageable. It's got 9,000 people in it. So I've closed off routine posting now and I just do, um, I do questions once a week and I do videos and stuff. But we set it up because I was going in all these groups like for eczema and allergy support and people are desperate and that's why you're going and looking for it. So I do get it. But if I see one more time your child's got eczema, it must be from milk, egg, take all this food out. Have you done elimination diets? I'm like, it's so dangerous. And it's not just the lay public doing it. And you're doing it to help people, that's a good reason for it. But if you don't have associated gut symptoms, it is not likely to be relevant. And eczema fundamentally happens because of genetic changes to your skin barrier. So when all these people are targeting you online saying what is the root cause of eczema, the root cause is genetics. And I can't stress that enough. And yes, there are things that turn it on and off, which we don't fully get. But anyone claiming that their course is the reason, you know, is going to find you that root cause. They're just, they're just manipulating you.

Dr Rupy: Yeah, that's crazy, isn't it?

Dr Helen: And I know because when I look at these things, because obviously I have a private company. So cards on the table and you know, we do provide support materials and things. Um, so I'll look. I get targeted too. And it plays on your mind. I mean, I think you know, the statistics showing, isn't there, if you're shown an advert like 10, 11 times, then you believe it to be true. So in the middle of the night, when you're all sleep deprived and your child's awake and you're screaming and itchy or you are as an adult, you're going to go, maybe that cream does work. I do it too. Maybe we should try that cream. And then I I'm quite science driven. I'm like, no, follow the science. But my lovely neighbor does it all the time. like, oh, I found this cream online and it's going to, you know, cure my wrinkles. And I'm like, oh, Steph, away from the advert. They're just targeting you. Yeah.

Dr Rupy: Um, are there any, uh, novel technologies or investigations that you're excited about in the future that could pinpoint allergies and intolerance more specifically, whether that's gut microbiome testing or, um, genetic testing to determine certain predispositions?

Dr Helen: I think we don't know. We do always get certainly in our allergy heralded, like we can cure allergies and and then you read into the article and think, oh, it's nothing really different from what we know. What would be lovely, I think, if we could really work out who are the people that are really at risk of the the really severe end of, like who are going to die from allergy. If we really could work that out, we could really target all our treatments towards them. I don't know if that would solve the whole problem though because I think it would, um, make light of the fact that still having anaphylaxis even if it's going to resolve and you're going to be fine, it's still pretty unpleasant to live with and stressful. And you know, you might be thinking, well, did you get it right? So that doesn't answer the whole story. I think the gut stuff is important. I do, um, think that there's a lot to be said for why is it that people who get chronic disease, and we talked before and I'm sure we'll touch on it about, you know, the fact that I had breast cancer in my early 40s. Why are we getting more of that? I do believe it's down to our diet in part and, you know, pollution in the environment and stuff. And knowing how we could identify that and manipulate it. And let's face it, we like quick, easy fixes. So if I could pop a pill and sort it out, we're going to. That would be great. Um, you know, better allergy testing would be good, but again, those talks have been around for quite a while. There's nothing really that new that, um, treatments for food allergy excite me. Um, having the fact that we are finally talking about therapeutics for allergies, treating it, um, preventing asthma, preventing allergy where we can. That that excites me and I think I think there'll be a lot of change in that over the coming years and I'm hoping to be one of the drivers of bringing that to the UK.

Dr Rupy: We've talked a lot about, um, history, diagnosis, you know, testing, all that kind of stuff. Um, let's talk about therapies. Is there hope for for folks? Like what what are what are the actual therapies apart from removal, if there is a true allergy.

Dr Helen: See removal isn't a therapy, is it? It's just a stopping it. And that that is all we ever used to do. We were essentially just a diagnostic service of come and see us. Here's your allergy and our strap line of our business is live well with allergies. And for many people, that's what we're trying to teach you the skills because not everybody is wanting treatment, suitable, can afford it because it is still mostly a private thing. But actually there are therapeutics that have been in other countries for years. And I again reflect back to hearing some of the narrative that you hear in hospitals when you're working there and you believe your consultants that you're with are gods and you trust them until you suddenly speak to someone else and they've got a different opinion and you start thinking, ah, I think I've been fed a pack of lies all my life. But I remember people saying, oh, basically what they get up to in America is just nonsense and they're just making up stuff in their back office and injecting people with this stuff and calling it immunotherapy. And now I'm like, oh, actually, no, it's us that are behind the times. And no, they're not just doing that in the back office. There will always be dodgy practitioners, but no, they're not. It is quite a measured and I'm part of a worldwide immunotherapy group where I hear a lot more about it. And we're just frankly well behind the times. Part of that is because we are a medical culture that's really driven by research and guidelines. And that has a place. But research takes so long to go through the processes to come out. Like the Natasha trial that's looking at milk and peanut immunotherapy, well, much of that is already being done. I do it every day. I know it works. But their data will be UK data which we need to create change, but it will take years to come to publication and that all those people missing out on that in the interim. So, yeah, we offer treatments to try and help. And the other thing then is around those early environmental allergies. So dust mite and grass pollen, for instance, and knowing that actually if you offer sublingual immunotherapy, so that is essentially dissolvable tablets of dust mite or grass or drops under the tongue that they have daily, it can reduce asthma forming by 50%. Wow. And we've known that for a long time and we don't do it. And if we look at what of all of the atopic conditions are you more likely to die from, particularly in the UK, it's asthma every day. And we've got huge rates of asthma deaths. So if we could prevent it, why aren't we?

Dr Rupy: Gosh, yeah.

Dr Rupy: Talk me through immunotherapy, how what's the um mechanism behind it, why I mean, we've talked a bit about why we don't use it in the UK. I think just behind the times, but um what what is the the story behind that?

Dr Helen: So immunotherapy is the only thing we have to try and create change. So it's trying to manipulate your immune system and build tolerance essentially. It generally isn't a cure. Although, like I say, it can be used with sublingual immunotherapy for environmental to try and prevent disease. Um, but there is some thoughts that if you do it for food early enough, maybe we will create permanent change for them and that's where I'm really excited. So basically, if it's environmental allergies we're talking about, then on the whole what we do is we just give you either a steady dose of what you're allergic to. So we can do it privately for grass pollen, animals, so cat, dog, horse, tree pollen, um, house dust mite. On the NHS you can do it for all of those but not animals. On the whole. Um, we can do injections of pollen that are sometimes done as well. Um, and you have a steady dose for three years. Although the benefit's seen each year, if you don't do it for three years, it seems that the long-term benefit doesn't come. And the long-term benefit is felt to be 10, 15, 20 years. So that's sublingual or you'll refer to it as SLIT or if you were doing the injections, it's SCIT, so subcutaneous immunotherapy. And they do have benefit, but some of they do have a bit of risk as well. And then for food, the options we currently have in the UK are what we refer to as OIT, which people refer to as either oral immunotherapy or oral induction of tolerance. It's not a cure. And I think what's really challenging for people is they will go online on these Facebook groups and stuff and as I say, you're hearing what everyone across the world's doing. And in America, there are a lot more commercially driven than we are in the UK. And some of the programs masquerade as a cure. And they are not. And they're very clever with their language. It is a cure. We'll give it you. We'll talk about it. I'll do it privately. All they're doing is induction of tolerance. And what they're doing is when you do it for long enough, you can start to reduce how often you dose. So essentially, what you do is you eat what you're allergic to with me supervised to monitor for the risk of anaphylaxis. a person goes home and they eat that same amount every day for two weeks. And the starting dose should be small enough that your immune system doesn't recognize it. So it's trying to go under the radar of being recognized by the immune system. So the hope is it doesn't trigger an immune response. For some people it does, and we have to work hard to reduce the dose and and find that starting point because actually for many people with allergies, we've no idea where your threshold is to trigger a reaction. And 50% of people with a peanut allergy can eat half a peanut before a reaction occurs. And if you knew that, you might feel less anxious, but we don't know where your starting point is. So I've got a young girl who's having immunotherapy to peanut and actually she's reacting even at one milligram, which is actually a very small proportion of the population that would do that. 250 milligrams ish in one peanut. So think about one milligram is tiny. Um, so they eat it for two weeks, come back, roughly two weeks, it varies clinic to clinic, they get a bit more, stay with me for an hour, go home and eat that. And over whatever time expands depending on the food, but you're roughly talking usually about five or six months of treatment. We build them up to be able to eat a set amount every day. Many of us that provide it in the UK don't get to high levels of the food because a lot of the studies show that for instance with peanut, if you just eat one and a half, two peanuts a day, actually over time your threshold will be even higher. So you're actually 12 times more likely to pass a peanut challenge after a year, which is about 20 peanuts. So you don't need to eat lots every day to raise your threshold further. Okay. If it's a food that you're going to eat regularly like milk, we'll raise their threshold higher and higher so that you can incorporate it into your diet. But that's going to take longer. And so all the different providers do something slightly different. And I say all the different providers because in the UK you've basically got two. It's so I mean it's a little actually you've got three. You've got so you've got me, you've got a couple of colleagues in London, and then my lovely colleague in Birmingham does peanut and a bit of milk. And then I have a colleague in Scotland who does peanut. I also work in Ireland. That is it. It's a tragedy that we do not have more treatment options. Even privately. And it it's just literally like the most rewarding thing I've ever been involved in to see people come in from absolute nervous wrecks, with like times I have to throw a mum out of a room because of her stress levels and we want the child to eat the food. But if your mommy's crying, you're not going to eat. Sure, yeah. Like we go and take her for a coffee and someone looks after her. To like, the mums and dads now chilling with each other in the waiting room, having a chat, and the kids are all in my play, you know, like the clinic is like literally play. It's like sometimes I think we're a crash. But they're just playing or we've got a pool table for our older teens and um, it is so rewarding. But it can have challenges and hurdles along the way. And and it's hard because you actually are at higher risk of anaphylaxis through treatment, but you're doing it because you're offsetting it with if you're accidentally exposed to a peanut now when you're out at your party and you're a teenager and you're ill and you want to kiss another person and you don't know if they've eaten peanuts or whatever the food is, those things no longer become a worry.

Dr Rupy: Yeah, yeah.

Dr Helen: So that's food oral immunotherapy. We do have food SLIT, so it has lower risks with that and that is coming imminently in the UK. And then we have other versions that are here and coming. So you can wear a patch. That's for peanut. Um. Oh, so you don't need to go to clinic for.

Dr Helen: No, you just wear a patch. It's called epicutaneous immunotherapy. Wow, very cool. Um, so EPIT. However, it's again, this goes back to the research thing. Because it's a licensed product or will be, it's taking so long to come to market. I mean, I think we've just excelled it with other foods. I think SLIT will take over from that really than drops. Yeah. Um, and then some people use biologics to inject to reduce risk.

Dr Rupy: So biologics are

Dr Helen: Uh like um so the main one we would use is something called Omalizumab. And what that does is it binds the IgE and so you've got less circulating IgE to trigger a reaction. It's been used for a long time for asthma and it's been used for a long time for people with hives that are unresponsive to treatment. But now they have used it to see whilst you're having injections and it is every four weeks or so, your risk of a severe reaction has gone. But when you stop the injections, it comes back. So now they use it particularly in America to combine it with doing the food immunotherapy. The difference though is in America, it's a licensed product and their insurance companies cover it and they actually cover immunotherapy, whereas you do not get any insurance cover for food immunotherapy or or the biologics for that reason in the UK. So you're talking a couple of grand a month just for the injections. So for most people, that's just not a tenable option. And it does bring with it anaphylactic risks from the injection. So you're weighing up everything. Um, but what's lovely is at least we have these conversations to have with you and it makes now for what was my hour consultation to now be like I'm running out of time and I might need multiple. Um, but it's a very exciting time and we're about to offer it for adults too, which um, again, currently in the UK nobody does. And that's, you know, adults, it they're harder because trying to modify your immune system as an adult's harder. Whether these will be right for every adult, no, adults bring a lot of overlay, you know, anxiety, other health issues, you want to get pregnant, all sorts of things. But actually what I think will work well for adults is when we offer sublingual immunotherapy. So um, basically what you'll do is you'll go through different dilutional strengths of what you're allergic to and you just stick on that. And it's an easier process with less risks and less lifestyle modifications that you need to make.

Dr Rupy: So you so you can just take that at home, you don't need to be in the clinic when you're doing.

Dr Helen: So you'll have your first dose supervised like you would with the pollen and things. And every dose we up dose will be supervised, but you're talking about three appointments really. And then you're just stay on it and then at the end we'll do a food challenge to see has it brought you the benefit. It is not quite as successful as the food immunotherapy, but balancing off risk of much less risk of anaphylaxis. And with the food, they can't exercise for two hours afterwards. So they can play as normal activity, like if you come to my clinic, I swear I'm going to film it one day just so people can see the noise level. When people come for assessments, they go, 'Oh, I feel so much better because they thought they had to pin their child rigid to a sofa'. Like I do have some families that do that. And you're like, no, like you can't stop a child being a child. And if the treatment's worse than the cure, yeah, you know, the disease, why would you do it? So these kids are just bouncing. Some of them clearly have ADHD and they're running around raucous. And when they leave, we all go. And I identify with those children. It's fine. I just sit and adapt with them as they climb over my computer and I'm chasing them with a stethoscope. Um, but they're fun places to be. There's a lot of emotion in the clinic. It is absolutely exhausting to run them. But we all I've brought everyone into run them with my mom. My neighbor who's a language teacher is our receptionist, most highly qualified receptionist in the world. But she loves it. She speaks Spanish to the children when they come in. And um, my husband runs our business. He's not medical. My sister-in-law does some behind the scenes stuff. Um, my mom does website. Like all of our family have bought into this because it it changes lives.

Dr Rupy: Yeah, that's incredible.

Dr Helen: And what we're hoping is that by being private providers and showing people these options are available, there is this push on the NHS to say, we should be offering that. It comes down to time and resources. And it's a a really hard balance at the moment. We do have a licensed peanut treatment in the UK called Palforzia, which is just capsules you open with peanut flour. Um, but the reason hardly anyone is offering it despite NICE approval, which means we should be, is because we haven't even got capacity to assess people with their allergies in the first place. So I do understand that because you can't justify giving one child peanut treatment and 30 children haven't even been seen.

Dr Rupy: Yeah.

Dr Helen: And that's that's but that's not on the allergists or, you know, that's on the NHS to sort itself out.

Dr Rupy: Yeah. Yeah. Um, I mean, it it sounds incredible. The clinic's amazing, you know, all these different support groups you have as well and the different staff. This all came about through personal experience that you've alluded to throughout this pod. What what was, because you you were a surgeon and you went into general practice and you you specialised. What was your journey into this with with your own children?

Dr Helen: So I wanted to be a surgeon and I did a few years of surgery first. And I did love it. Um, I cardiac thoracics just ruined it for me. I was always the leg end trying to strip a vein. not being able to see what was going and I just thought, I just don't think I can have the quality of life I wanted and wanting children. Now I actually feel really sad about that that I didn't feel. I literally said to people at the time, you can't be a good parent and a good surgeon. I totally disagree with that. You can be good at everything. You just have to balance off. Um, so probably better mentors would have helped with that. But anyway, I'm glad that happened to me. So I swapped to be a GP. I was training, got pregnant with Ethan. And then, he was on intensive care, a difficult start. I remember at the very beginning saying to myself, while he was on intensive care, I don't want to be that parent that always now says he's got weak lungs because he was on intensive care. because we hear that narrative a lot and it's often not true. There are some cases, of course, if you've had oxygen dependency and things. And so I I sort of right from the start of his life made decisions about how I wanted him to be brought up with I want him to do everything. But we then followed this pathway of eczema and then what I now know as non-IgE symptoms. At the time I didn't. So I went to his neonatologist who said, cut milk from your diet. did, he got better. I never actually put two and two together with that. I feel like I sound so unintelligent. sleep deprived. I didn't put two and two together. I actually thought the reason he got better was because we went on holiday to Portugal. It was a nice chill time and he slept for the first night. Now I look back and go when I cut milk, obviously. But anyhow. So his dad didn't ever think he had a milk allergy. He was like, I just don't think. And he's a doctor too. He he said, I don't think he does. So weaning at home alone, I thought, fine. So I gave him dairy lee cheese as you do. And then within minutes, his face swelled up and he was covered in hives. And I don't, how old was he at this point?

Dr Rupy: He was six months old.

Dr Helen: And I just don't think anything prepares you for it because actually I don't think that many doctors have seen allergic reactions happen in front of them and certainly not to your precious human beings. So I remember ringing Dwayne, his dad, and saying, 'Oh my God, Ethan's like this has happened'. And he was like, 'Well, call an ambulance if it's that bad'. And I was like literally said, I don't know if it's that bad. I just I didn't have anything to hang it off. And I always say to people, and I was a doctor. Yeah. So I ran to the chemist like a crazy loon and said, 'Give me some antihistamines'. And they were like, 'Oh, it's not licensed, you can't have it'. I was like, I'm a doctor, just give me the antihistamine. And I have vivid memories of being in the park feeding Piriton and he got better. Um, and then I fed him porridge which had cow's milk again, didn't think about it. And um, I was like, this is weird. What's what's in porridge? It's oats, but it was milk. Was it a separate day? a separate day. Um, so he was referred through and essentially what followed were all these hospital appointments. We did have a great consultant. But what I reflect back on is that people made assumptions about my level of knowledge, I think. And nobody explained to me like how to read a food label, which at the time was more complex with no, nothing in bold. So I missed it. they didn't, maybe this sounds so stupid. Nobody actually said to me, make sure you check every single packet. So I didn't. I just I went like, oh, it's an ice lolly, what have milk in it? You know, I made assumptions and nobody told me about the different symptoms of reactions, how to use epi pens, um, or when you would even need it. No one told me that might happen. So he then had anaphylaxis twice. The most notable time which I do laugh about now because I think you just have to. But we were in Weymouth. I gave him a silly balls, hadn't checked the packet. There's a recurring theme that had gone on for him. And he started coughing and I thought he was mucking about because he was about two and a half and it was at a stage where toddlers often start doing this fake cough. So I was like, oh, Ethan, stop coughing. And then I put him in the car and we were traveling home and because I wanted to get him to sleep, you haven't probably got this yet, but you don't look at a child who's trying to sleep. So you just don't make eye contact. And the whole way home, he coughed and the whole way home I told him off. And when I got him home and got him out of the car, he was absolutely covered in hives and really swollen. So I picked up the packet and it said milk, quite obviously. I mean, honestly, now, how I'd have ever lived with myself if something happened, I don't know, but it does come back to the lack of education I had. And so I gave him antihistamines and inhaler. And what was probably going on at that time is he had unrecognised asthma. And he got better and I said to his consultant, it's a really weird reaction happened to Ethan. He was like, well, that's anaphylaxis. I said, no, it's not. Like I said, he wasn't collapsed. And I'm not alone in that because we know from audit after audit, people do not treat anaphylaxis properly. He got better because most people do, but if he hadn't, and there are children of that age that can die, I'd have never ever managed to live with myself again. I just I think he is my pride and joy and it just would have been the end of the world. So he said, I really think you need more training. So I went back to university when I was pregnant with my third. Also an interesting time because I was going to university literally on my due date with with like people making bets of will she arrive. I was with my due date, got my best result ever breastfeeding with a newborn. Um and I was going, what can I do to my child to make sure that this one doesn't have any allergies because my other two do. And at the time, it was felt that if you moisturize your child from day one, repairing their skin barrier, they'd be less likely to have allergies because of that exposure over the skin. What we've since found out with a bigger study is actually you increase their risk of allergy forming because you transfer food proteins across once you've eaten and in the moisturizer. So, very lucky that GG Genevieve has only got mild eczema, but not the irony that she's got some eczema when I'm moisturizing from day one. Yeah. But nothing else as it currently stands. Um, and Ethan did outgrow his milk and nut allergies when he was eight. Oh great. Um, but he's got environmental allergies. He's got quite worrisome asthma that he won't acknowledge. I literally, I get my children say to me, what do you know? And I'm like, I have two degrees and one of them is in the area of eczema and asthma. So probably quite a lot. Um, and yeah, he has quite worrisome lung function, but he sort of clinically doesn't have a lot of symptoms, but you know, a couple of my colleagues have said he will have scarring if he doesn't do something about it. It's really hard talking to teenagers about compliance. And again, I reflect back to why do these things happen to me. So I do, as I said, I do believe that for us as a family, we like to, I like to think about situations with the positive light of why does it happen? And I think it happened because it helps with because we changed everything about our lives to help other people and I think we're having an impact on other people's lives and that came because unfortunately for my children, they've lived that and we've lived that. Um, and so, you know, having a teenager where you're having these conversations, again, I hope it helps me approach other teenagers to to be empathetic and understand how their parents are feeling and also like it's no point just saying just do it, it's not going to happen and coming to the middle ground with them. But ultimately it is their choice because it's their body. Yeah. So, so yeah, we sort of navigated all of that. And then as you know, I had breast cancer and the about 18 months ago-ish now and had, um, the diagnosis of aggressive breast cancer. And again, the reason I think it happened is because like I actually work even harder now than I did then, but it allowed me to take time out of the NHS because I was told I was doing a job where I would go and visit the elderly at home. So I looked after the frailty for my GP job, very different from allergy. And, um, they said with the chemotherapy, the risks of infection to you are too high. So you can't do that. But I said like, I have to earn a living. I'm self-employed. My husband and I both run our business and we've got two children that have just started private school and five children between us, bills to pay, no one's going to pay our bills. And nobody actually really like helped me. I wanted good stories of who's managed to work through chemo. And I literally just got, 'Why don't you just have a break?' Which did my head in because also I'm not really a person as you might see. But like I'm like the worst person. No, the days that chemo got me, I was really pathetic and literally lay on the sofa crying that I couldn't go to work because I was like, I've got people to see. It really affected me not to work. It affects my mental health much more than going to work. Wow. Um, anyway, I did manage to work out with the chemo of what days could I work and what days could I not work. So we had about six months of chemo and it meant that I had time to really focus on the allergy, building the membership. And now we have, you know, two units in Ringwood, uh, another branch in Belfast. And a new private GP, Dr. Helen Medical that's just opening this week. And, um, and I I think it was because it gave me time to redirect it rather than because I actually really love being a GP. But I couldn't do everything. And so I had to pull back the home visiting bit for the business. And the more I've delved into it, the more I've realised what a niche I can forge and how instrumental I can be in bringing something to the UK, which as I said to you before, reflected on when you're in hospital and you say to people you want to be a GP, all you get from unfortunately from many hospital colleagues is what a waste. Which is so annoying for GPs because in your most of your phases of your life, you're going to meet a GP that you're going to want. If you're dying and your end stages of your life, it's usually me or my colleagues who are looking after you well. Um, but what I've actually shown is you know what, I can be a GP and I can be one of the top specialists in the UK driving something forward. And I get a lot of imposter syndrome about that and having little stress on the way here that you're going to throw questions at me that I don't know the answers to. Um, I know what I know and I know what I'm good at, which is patient communication and doing things for people. And and yeah, just it showed me that really just very clearly that I could do that.

Dr Rupy: I think imposter syndrome, honestly, is a sign of like someone who just keeps it really humble and is usually, you know, most people I've sat opposite, uh, on this part have got imposter syndrome. It's just a sign of an an incredible person and greatness. And like, I mean this honestly, Helen, you're such an inspiration to me having, you know, got to know you over the last couple of hours. As a as a colleague, as a parent, I'm a new parent now of a seven month old, so I've got a lot of these things to to look forward to, you know, when he starts walking and talking back and all the rest of it. But also as a as a business person as well, as an entrepreneur, like it's so inspirational hearing about your journey and how you're, you know, turning your passion into your livelihood. It's it's it's amazing. And for any other health professionals listening to this, whether you're a nurse and a like health professional or another doctor, um, hopefully they'll they'll they'll find inspiration in this as well.

Dr Helen: Yeah. I am going to just say I wouldn't be able to do it without my husband. I I do have because he has literally been the person there picking up the pieces the whole way through.

Dr Rupy: That's incredible.

Dr Helen: And I'm going to not, you know, not going to disrespect my ex-husband, like we were together for 18 years, but we always have a little joke that towards the end of our marriage, he used to say to me, I'm not here to support your international career. And my new husband says, I am here to support your international career. And next week we're going to America to go and speak with other allergists out there. Amazing. And like honestly though, like it takes for us to build that business, we couldn't do it without each other. So he is the quiet person behind the scenes that you'll meet in clinic because he loves it. But he doesn't take any credit for it. But you just, you can't do everything alone. You need that support around you, don't you? to develop stuff.

Dr Rupy: Yeah, I think that's a cue to say the same about my wife as well. Um, as she knows. Um, if there are two or three things that you want to leave our audience with in terms of the top tips or things that you want people to understand at the end of this pod, reflecting on what we've talked about, what do you think would be the key things you want to remind people of?

Dr Helen: I think when you fall you come into the path of allergy, either because you're a parent or you're a person yourself, it it is okay that it feels like you know, that you're losing something. I think it's any chronic disease makes you feel like that. It's not the journey you thought you were going to follow with your child or for yourself. So giving yourself time to grieve what you lost is really important and that's okay to do that. But then it's the picking yourself up and going, what can I spin to you know, know what what actually has it brought us? It might be that it's brought you a new allergy community and friendships, a deeper awareness of other people and, you know, you're new found cooking skills or whatever it might be, there will be something. And whatever your child or you can absolutely still lead an an amazing life. It doesn't have to stop you, whether you're treating those allergies or not, you will still have a fantastic life and you absolutely can do that and support your child to do that too.

Dr Rupy: Amazing. Thank you so much, Dr Helen, that was great. It was phenomenal, phenomenal, phenomenal to listen to.

Dr Helen: Oh, thank you. It's been a joy to chat.