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Join Kara Wada, an adult and pediatric allergy, immunology, and lifestyle medicine physician, as we discuss the epithelial barrier hypothesis. What is the epithelial barrier hypothesis? What are some of the diseases that have been linked to epithelial barrier dysfunction? What are some of the factors that can disrupt the epithelial barrier? How can we protect our epithelial barriers? What are some lifestyle changes that can help to improve epithelial barrier function? Find out the answers to these questions and more in this episode.

Kara Wada is a board-certified academic adult and pediatric allergy, immunology, and lifestyle medicine physician, Sjogren’s patient, certified life coach, TEDx speaker, and Dr. Midwest 2023. She can be reached at Dr. Kara Wada and on Instagram, YouTube, Facebook, and LinkedIn. She is a national expert, sought-after speaker, advisor, and host of the Becoming Immune Confident Podcast. She is CEO and founder, The Crunchy Allergist and the Virtual Sjogren’s Summit, and serves as the director of clinical content for Aila Health.

She discusses her KevinMD article, “How modern lifestyle changes are disrupting our immune systems.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Kara Wada. She’s a board-certified academic adult and pediatric allergy, immunology, and lifestyle medicine physician. Her KevinMD article is titled “How modern lifestyle changes are disrupting our immune systems.” Kara, welcome back to the show.

Kara Wada: Thanks so much for having me again, Kevin. It’s nice to talk again.

Kevin Pho: So you’ve been on the show multiple times. Just go to KevinMD.com/podcast, go up to the right-hand corner, where there’s a search bar, search for Kara’s name, and you’ll hear her story in prior episodes. But today, let’s jump right into your latest article, “How modern lifestyle changes are disrupting our immune systems.” How did your article come about?

Kara Wada: Earlier this year, I was able to go to the American Academy of Allergy, Asthma, and Immunology meeting for the first time in about five years, due to COVID and having children and everything. I was really excited to see one of the areas that interfaces completely with the area I’m most interested in clinically, which is lifestyle and the increased prevalence of these allergic and immunologic conditions that I see day in and day out.

One of the leading theories that has taken hold, and was discussed quite a bit during the meeting, was the idea of the epithelial barrier hypothesis. So I wanted to talk a little bit about this theory, explain it, and educate others reading about it, but also talk about some of the simple things we can do in our everyday lifestyles to modify our risks as best as we know.

Kevin Pho: All right, so let’s start there. What is the epithelial barrier hypothesis, and why is it important?

Kara Wada: Our epithelial barriers are our interfaces between our body and the outside world: our skin, our gastrointestinal tract, and our respiratory tract. These are the areas where our immune system is very active, because it is trying to help protect us and determine what is friend and what is foe. But it’s also, in part, our armor. There are certain things we’re exposed to, especially within our modern existence, that essentially create chinks in the armor. When we have those breaks, or those chinks in the armor, we have increased communication between the outside and the inside at that interface.

As well, we are increasingly aware of the role of our microbiome, so the bacteria, the viruses, the fungi, and all of those other organisms that live on and in us. There’s this delicate interplay between the outside, the inside, our immune system, and the microbiome, and those can all change when there are breaks in that barrier.

Kevin Pho: So talk about some of the conditions and symptoms one would feel if there are breaks in that epithelial armor.

Kara Wada: Yeah, so, things that I commonly see in the office. Eczema is one of the paradigms of a problem with our epithelial barrier, the skin. Either because of a genetic difference, like a variation in our filaggrin gene, which we know is a common cause of pediatric eczema, or because of exposures to things like air pollution as adults, we can have increased leakiness of our skin barrier. As a result, our skin can become more sensitive, or sometimes even allergic, to things we put on it. So one of the mainstays of treatment of eczema is to remove those aspects that are more inflammatory.

Increasingly, we’re learning that treating or adjusting the microbiome, so the types of staph that live on our skin, can also contribute to an increase or a decrease in the permeability, or the breaks, in the skin. All of these things will play a role in how we are able to help and to heal.

Kevin Pho: So you mentioned eczema as one example. Tell us some other examples.

Kara Wada: Eosinophilic esophagitis is another increasingly common condition that we didn’t even know existed around the time I was coming onto this planet. And we know that, increasingly, other types of autoimmune conditions, for instance rheumatoid arthritis, have some cases that are linked to changes in the gut microbiome, and linked to increased permeability in the gut and to reactions or inflammation directed toward certain microbes that live in our gut as well.

Kevin Pho: In your article, you also gave examples of some pulmonary conditions that may also be related to this.

Kara Wada: Yeah, so everything from allergic rhinitis to asthma as well. And then there are some links between air pollution and eczema, and also multiple sclerosis as well.

Kevin Pho: So take us into your exam room. Give us a case study or a story of how you would use the epithelial barrier hypothesis in your exam room to guide your questions to the patient.

Kara Wada: Yeah, so I recently met with a young Asian woman, a mom in her mid-30s. She worked in the beauty care industry, and she was dealing with a lot of eczema and rashes on her hands. So we talked a lot about things she could do to minimize her exposure to some of the things that were aggravating her symptoms. One was to switch to a milder soap, and to wear gloves to increase the barrier.

Then we talked about some ways to help repair the barrier. There are some particular probiotics that may be helpful, and ingestion of a particular type of ceramides can help repair the barrier. We also talked about trying to minimize her exposure to some of those really effective surfactants, or soaps, that she’s using when shampooing hair in her line of work. So wearing gloves during those times, and being really cognizant of using a mild but very moisturizing lotion or cream at nighttime as well, were things we discussed.

Kevin Pho: And how did she do?

Kara Wada: So I have not followed up with her. This was just within the last few weeks, and we have planned follow-up in a few weeks. But with similar patients over the years, I’ve seen a lot of improvement with some of these really simple changes that we can make in our everyday habits.

Kevin Pho: So talk to us about some of the other everyday things we can do to help reduce the damage to this barrier.

Kara Wada: Yeah, so for our skin in particular, we can pick either hot water or soap, not both, except in those areas that do get a little bit smelly, especially during the summertime. If we think about the fats that are on our skin, those natural oils, think of them as akin to butter. When we think about cleaning butter off a dish, hot water does a pretty good job of just rinsing that off. If you’re using both hot water and soap, that can overstrip our skin. So especially if you’re prone to dry skin or rashes, this can really minimize the damage and optimize our natural barriers.

I also really recommend skipping fragrance, dryer sheets, fabric softeners, anything that is kind of the extras. Those are common allergens, but they also contain other substances that can affect our hormone, or endocrine, system as well. And then, when feasible, choosing natural fibers can be helpful, especially for those who are really prone to rashes or have sensitive skin.

I know my husband, for the longest time, loved his no-iron shirts that he picked up from one of the main stores. But those are treated with a formaldehyde-like substance, which is what allows them to stay wrinkle-free. I will say he still did have to iron them, so they weren’t that helpful. But it’s just one more chemical that we can pretty easily avoid. I don’t want to scare people into thinking all chemicals are dangerous, but if we can minimize our exposure to things through really easy swaps and simple switches, then this can be really helpful.

Taking your shoes off when entering your home helps you minimize bringing in certain bacteria and pollution. If you’re using a gas stove, running the exhaust fan can be helpful. That’s another aspect that has increasingly been under study and in the news, as a common pollutant that we’re exposed to.

And then, for our gut, try to minimize our exposure to ultra-processed foods that contain emulsifiers and additives, which we know are detrimental to those good microbes. Those are going to be the ones that help reinforce, or strengthen, that gut barrier. Increasing our daily fiber, slowly and surely, is another way to help improve that gut health as well.

Kevin Pho: Let’s talk about the primary care setting. Tell us a common scenario that I, as a primary care physician, may see in the office, and tell me what kind of questions I should be asking that patient.

Kara Wada: Yeah, so I would say one of the most common referrals I’m getting from my primary care colleagues is worry about food allergies. When I really dig in and talk with the patient about what they’re experiencing, it’s gas, bloating, stomach upset, and just having bowel function that is not ideal, leaving them pretty miserable on a daily basis.

I think some of the questions we can start with are: What does your daily diet look like? What does an average day of your eating look like? How often are you turning to convenience foods, whether it’s prepackaged or takeout food? We’re just trying to get a sense of how much ultra-processed food is coming into the diet, and also listening for how much fiber is really part of the diet.

Looking back and thinking about my childhood, a perfect meal, from probably age five up until even my early to mid-adulthood, and I hate to admit this, but even into medical school, would have been a bowl of cereal or something like a Toaster Strudel or a Pop-Tart for breakfast. For lunch, a grilled cheese sandwich with fries, and for dinner, kind of the typical meatloaf, mashed potatoes, and corn that I grew up on. Thinking about it, aside from maybe the mashed potatoes and the corn, there’s not the nutritional value, the fiber, the things to help feed and help our gut health, in that American diet.

So those would be things I would be thinking about asking about. And then I’d talk with the patient about: OK, what are some really simple ways that you can start introducing some of those more whole-food, fiber-rich ingredients? Is there an easy way to have some whole-grain toast in the morning, or some oatmeal, or a smoothie that would still be as quick and easy as running through the drive-through but be much more beneficial for their overall health, and in particular help with their symptoms as well?

Kevin Pho: Now, what kind of cases or patients should we consider referring to an allergist like yourself?

Kara Wada: Certainly anyone who is dealing with difficulty swallowing. That would be something where an allergist, along with a gastroenterologist, may be helpful if we’re concerned about eosinophilic esophagitis. We are always happy to help with patients who are dealing with eczema, and with chronic hives, where we’re starting to see some evidence that the microbiome may be playing a role as well. And certainly our patients dealing with increased issues with their allergies. Along with our modern existence and some of the climate change issues, we’re seeing increased pollen counts, and so increasingly we’re seeing those affect patients in significant ways: not only runny noses and itchy, watery eyes, but significant allergic asthma.

Kevin Pho: She’s a board-certified academic adult and pediatric allergy, immunology, and lifestyle medicine physician. Her KevinMD article is titled “How modern lifestyle changes are disrupting our immune systems.” Kara, tell us some of the take-home messages that you want to leave with the KevinMD audience.

Kara Wada: I think the big thing is that our daily habits really are what make or break us and our health for the long term. If we are able to make some of these really simple little switches to minimize the potential for creating chinks in that armor, so making little adjustments to our shower and skin care routine, increasing the fiber in our diet slowly but surely, and improving our air quality, it really can make a significant difference in our health over the long term.

Kevin Pho: Kara, thank you so much for coming back on the show and sharing your time and insight.

Kara Wada: Thanks so much, Kevin. Take care.