In addition to a steep increase in prevalence, in recent decades, we have seen an evolution in the ways our immune system misbehaves: eosinophilic esophagitis, mast cell disorders, and early onset colon cancer, among many others. This data alone should remind us that we are an ever-evolving species. With our rapidly changing lifestyle over the last century, it shouldn’t be surprising that we are seeing some sort of physiologic hangover.

As one of the handful of lifestyle medicine-trained allergy immunology physicians, I find myself increasingly talking about the entirety of the exposome: the summation of all of the things we are exposed to in our lives. Everything from viral infections, early traumatic events, the food we eat, and the air pollution we inhale is a potential culprit for us to point a finger at when looking for a reason for all of this suffering.

In reality, a mixture of these variables extoll their effects on susceptible individuals flipping the epigenetic switches and putting chinks in our armor-disrupting the delicate balance that exists at the interface between outside and inside: our epithelial barriers. As our understanding evolves through the work of scientists like Dr. Cezmi A. Akdis, the hygiene hypothesis has evolved into the epithelial barrier hypothesis: the theory that disruptions in our skin, respiratory and gastrointestinal tracts are at the root cause of many of our diseases of modernity: allergies, asthma, inflammatory bowel, and Alzheimer’s to name a few. We see shifts in our microbiome and the inflammatory cascade when the barrier is broken. We are still seeking to understand how best to prevent, repair and rebalance.

In the meantime, how can we approach this paradigm shift as we discuss our patient conversations? How can we minimize the insults and reinforce our defenses as we go about our busy modern lives?

For our skin:

• Choose hot water or mild soap, not both, except on the sweaty smelly parts to help minimize removing too much of our body’s natural oils.
• Skip fragrance, dryer sheets, and fabric softeners. They are common allergens and often contain endocrine-disrupting chemicals.
• Choose natural fibers when feasible. Many synthetic fibers are treated with formaldehyde, PFAS (forever chemicals), flame retardants, and AZO dyes.

For our respiratory tract:

• Take your shoes off at home, vacuum, and wet mop regularly to minimize bringing in certain bacteria, pollution, and pollens.
• Run the exhaust fan while using a gas stove to minimize exposure to harmful particulates that are created while cooking.
• Open your windows and/or consider using an air purifier. We spend 90 percent of our time indoors, but indoor air quality is 2 to 5x worse than the air outside typically. An air purifier may be helpful, especially if the windows need to stay closed during pollen season for those with significant allergies.

For our gut:

• Avoid ultra-processed foods as best able. Emulsifiers and other ingredients increasingly are being implicated in injury to the gut lining and poorer health outcomes.
• Work to increase daily fiber intake, especially with fruits and vegetables. This helps reinforce our natural barriers and eliminate waste better too.
• Minimize plastic use as best able, opting for glass, stainless steel, ceramic, or silicone, especially when microwaving leftovers. We ingest an average of a credit card’s worth of plastic each week, and these microplastics damage our gut lining.

At the core, though, we must remember to do the best we can with our knowledge and bandwidth. When in doubt, keep it super simple, start small, and let things snowball over time. Last but not least, I always return to the idea of progress over perfection because the reality is that stress has its own physiologic can of worms to contend with – more of it is rarely helpful.

Kara Wada is a quadruple board-certified pediatric and adult allergy and immunology, lifestyle, and functional medicine physician, a Sjögren’s disease specialist, and a Sjögren’s patient herself. She spent nine years on faculty at The Ohio State University Wexner Medical Center, where she served as associate program director of the allergy and immunology fellowship and led the Mast Cell Center of Excellence.

In 2025, she left academic medicine to build the kind of practice she could not find as a patient: the Immune Confident Institute, a national direct-care immunology practice licensed in 27 states. She treats the patients the health care system sends ping-ponging between specialists, people with complex, chronic, multisystem disease including mast cell activation syndrome (MCAS), dysautonomia, Sjögren’s disease, immune dysfunction, and the seronegative and “in-between” diagnoses that do not fit neatly into a single specialty.

Her premise is simple: These patients are not the problem. Fragmented care is. Medicine has become exceptionally good at looking through microscopes while losing sight of the telescope, the bigger picture of the person in front of us. Her work challenges a health care culture that demands compliance when it should assume competence, and aims to make strategic, compassionate immune-directed care the standard, and the exam room a place where patients are finally seen, heard, and believed.

Most of her reach is built outside the exam room. Her YouTube channel drew roughly two million views this past year, and more than 100,000 people follow her work across platforms, including a Sjögren’s community of about 6,600. She founded and hosts the Virtual Sjögren’s Summit, now in its sixth year and drawing some 4,300 registrants worldwide. She appears regularly on national television and in the health press, including Prevention, SELF, Good Housekeeping, WebMD, Medscape, and MedPage Today, and she writes for KevinMD on the diagnoses that live in the shadows and the medical gaslighting that surrounds them.

A TEDx speaker and sought-after keynote, Wada speaks to clinician and patient audiences about complex immune disease, the experience of being disbelieved, and what changes when the physician is also the patient. She is also an unlikely pageant titleholder, having served as Dr. Ohio America 2022 and Dr. Midwest America 2023, and has written about how pageantry sharpened skills medicine rewards but rarely teaches.

She earned her medical degree with honors from the University of Illinois College of Medicine at Peoria and completed internal medicine-pediatrics residency, allergy and immunology fellowship, and clinician educator fellowship at The Ohio State University and Nationwide Children’s Hospital. She lives in Columbus, Ohio, with her medical school sweetheart turned husband, Akira, and their three children.