Prof Pete Smith: A Holistic Approach to Allergies & Chemical Sensitivities Introduction

Well, today we are going to be exploring the world of allergies. And it is a big topic. It is one that when you hear it, you’ll be amazed that we don’t all suffer from allergies. It may surprise you that 20% of the population do, officially, but it’s a testament to the human body that we don’t all when you consider some of the factors involved in it.

So my guest today is Professor Pete Smith. Now Pete is one of Australia’s leading allergists. Pete commenced his medical studies at the University of Tasmania and went on to specialise in paediatrics in Adelaide before completing his PhD in molecular immunology.

Pete has a clinic on the Gold Coast in Queensland in Southport, where he provides patients with the highest level of quality medical care and the diagnosis and treatment of allergies. He takes holistic to a whole other level and it’s a real treat to hear him just piece it all together.

He’s also a Professor in Clinical Medicine at Griffith University and Bond University. He currently conducts research studies into the molecular aspects of pain in allergic conditions.

He’s an active member of the Australasian Society of Clinical Immunology and Allergy and a regular expert commentator in the media. And you will see why. I hope you enjoy this conversation I had with Professor Pete Smith.

Podcast Transcript

Dr Ron Ehrlich: [00:00:00] I’d like to acknowledge the traditional custodians of the land on which I’m recording this podcast, the Gadigal People of the Eora Nation, and pay my respects to their Elders – past, present and emerging. 

Dr Ron Ehrlich: [00:00:20] Hello and welcome to Unstress. My name is Dr Ron Ehrlich. Well, today we are going to be exploring the world of allergies. And it is a big topic. It is one that when you hear it, you’ll be amazed that we don’t all suffer from allergies. It may surprise you that 20% of the population do, officially, but it’s a testament to the human body that we don’t all when you consider some of the factors involved in it. 

So my guest today is Professor Pete Smith. Now Pete is one of Australia’s leading allergists. Pete commenced his medical studies at the University of Tasmania and went on to specialise in paediatrics in Adelaide before completing his PhD in molecular immunology.

Dr Ron Ehrlich: [00:01:02] Pete has a clinic on the Gold Coast in Queensland in Southport, where he provides patients with the highest level of quality medical care and the diagnosis and treatment of allergies. He takes holistic to a whole other level and it’s a real treat to hear him just piece it all together. 

Dr Ron Ehrlich: [00:01:20] He’s also a Professor in Clinical Medicine at Griffith University and Bond University. He currently conducts research studies into the molecular aspects of pain in allergic conditions.

He’s an active member of the Australasian Society of Clinical Immunology and Allergy and a regular expert commentator in the media. And you will see why. I hope you enjoy this conversation I had with Professor Pete Smith. Welcome to the show, Pete.

Prof Pete Smith: [00:01:48] Thanks so much, Ron. Pleasure to be here.

Dr Ron Ehrlich: [00:01:50] Pete, I’ve been looking forward to speaking to you for some time now and you’ve got an incredible background. Can you just give us a little bit of your journey that’s taken you to this point professionally?

Prof Pete Smith: [00:02:02] Yeah, look, I guess I was gruff as a kid saying doctors as an esteemed person in a community, somebody that was could look after people, could change people’s lives. So that was aspirational kids from even about ten years of age. So it was a pursuit there. 

I did university and part of that I enjoyed the aspect of paediatrics in that we could make people better. It wasn’t part of stopping the decline, which a lot of health care is, and bandaids as people just slow the decline. Kids got a better bounce back and yeah, still rewarding. I found that as an area of interest.

Prof Pete Smith: [00:02:42] When pursuing that as a specialist, I became very aware that allergy and immunology just clicked with me. The molecules and the mechanisms seem to make sense and at that stage, in the very early nineties, it was looking like Immunodeficiencies, which again took me back to holding people together as they died or HIV medicine. So allergy was something that was really only designed to be defined at that time. 

You know, I’m talking about nearly 30 years ago when I was making those choices. And that was still the stage where we were relying on books and journals and publications and libraries and faxes to get information. And IgE is a molecule was only really defined in 1966-67 by the Japanese and Swedish researchers. 

Dr Ron Ehrlich: [00:03:35] IgE – Immunoglobulin E. 

Prof Pete Smith: [00:03:38] It was only that it was the lightest one to be picked up because it only represents 0.1% of our total immunoglobulins that we make. So it’s there in very small amounts, but when it goes awry, it can really define severe phenotypes and diseases in people. So linking that to journal papers, linking that to studies and then to textbooks to practise really was a deficiency and still remains a deficiency because of relatively fixed curriculums. Curriculums aren’t fluid. They tend to be what works and will do that again. So to get something new in curriculum, it takes a massive shift in change, and it gets largely based by the specialist you have in hospitals. 

And allergies is something that doesn’t keep people in hospitals. So hence Australia didn’t have the passion to have large hospital allergy departments and it crosses several disciplines. It actually crosses respiratory, skin, it crosses gastrointestinal and as well as allergy with anaphylaxis.

So existing departments sort of dabbled in it and climbed that space. Kind of a bit of a battle like hand injuries where they belonged to orthopaedics, plastic surgeons, specialised microvascular people, and neurosurgery. It’s a lot of argument what that is.

Prof Pete Smith: [00:05:07] So allergies didn’t really define it as space and hospitals were already having to fight for existing services. So we didn’t see the growth like we did in the US where allergy departments were set up. Again, probably because in large clinics like the Mayo, Cedars-Sinai, we’re actually seen as an outpatient service. So this would actually bring revenue to the hospital. So again, the government system didn’t see that develop. 

So going back to the early nineties, we could solve problems and it really improve people’s quality of life by addressing allergies and identifying… So great detective hunt. And so I did my PhD in molecular immunology and then went over to the United Kingdom. I had the privilege and honour to work as a consultant there at Great Ormond Street, which is I used to run their food allergy clinic between 1999 and 2001. 

Prof Pete Smith: [00:05:59] So I was there for three years and I was getting to that stage in my late thirties and making a decision whether I should come back to Australia or whether I end up in the UK all the time. It was a pretty easy choice. I want to come back to Australia. I have family here. So I made the choice to come back and I set up in Queensland and have a practise here on the Gold Coast. 

I was in Brisbane working with an adult colleague for a couple of years and now I see both adults and kids and I have a GP-based practise called Allergy Medical in Brisbane which I supervise. I attend there once a fortnight. We discuss cases regularly, virtually every day with the doctors. It’s because a lot of allergy care can be done at a good primary care level. If I had the time and resources and the backup as well in the protocol. 

Dr Ron Ehrlich: [00:06:48] So tell me, I mean, we’re going obviously to talk about allergies, but I wondered if you could just give us Allergy 101. You know, what is it and how common is it? 

Prof Pete Smith: [00:06:59] I can. It depends what form of allergy we have. If we’re talking about things like hay fever, or allergic rhinitis, probably about 20% of Australians have it. We see it in a lot of young children, adolescents, and early adult life. An allergy, going back a step, is an abnormal response to a perceived threat. So, you know, dust mites and grasses and peanuts are pretty not that dangerous, but our immune system gets it wrong.

Dr Ron Ehrlich: [00:07:28] Hmm.

Prof Pete Smith: [00:07:28] And you got to ask why and that’s going to be a multilayered answer as well. But we see allergic rhinitis might be 20-25% exceeding the amount of asthma. Australia has one of the highest rates of asthma in the world. At least 80% of childhood asthma is allergies involved. Probably a good 50% of adult asthma will have an allergic layer. 

We have food allergies, which occur in 5 to 8% of children. We have eczema. Where we get a significant amount of eczema can be driven by allergens as well. People question all. Can they or can’t they. That’s been proven in allergen chambers where they put it through the air conditioning to look at the treatment for rhinitis and they’ll say that people’s skin will flare up a douse and might drop to that allergy exposure. 

So we know that they can flare that up. And we’ve done there’s been a series of double-blind challenges with foods and seeing eczema flare up with or without those foods. 

Dr Ron Ehrlich: [00:08:23] Because that must be one of the I mean, one of the challenges is people associate allergy with being come in contact with something. I’ve started to sneeze, I’ve got a rash. It’s an immediate response, but sometimes it can take a little bit longer. And that’s where the detective work, I guess really creeps in, isn’t it?

Prof Pete Smith: [00:08:41] It is. Some of these can be summative effects like you’re talking about people getting hives. We get rashes. There, we can get contact dermatitis, which is a Type 4 reaction, which will say somebody might walk past the grevillea and start to get itching 10 hours to two days later, which will flare up for up to two weeks. You think, “What on earth have I done?” And it’ll just be at that site and can be very aggressive. 

So that’s contact dermatitis. So when somebody’s undies are wearing a bit thin, the latex can cause, a latex rash or colophony, a very common adhesive that we will use in Band-Aids. And people get a rash there that will last for two weeks. We get colophony in pairs and transparent sideboards. You get pine sap on you. It’s an extract from the pine tree.

Prof Pete Smith: [00:09:25] Metal allergies tend to be… That’s in watches, jewellery. Nickels are very common. Contact allergy. Hives can come up because our bodies fighting something that it thinks is danger and they can be very exuberant. But it can also be a case where we make a mistake with ourselves. We found that many patients with chronic urticaria, where they get hot all the time, day and out, months and times years actually make IgE allergic antibodies themselves. 

They’re actually allergic to themselves, which is it’s a bit of a revelation that’s only really become come to the forefront in the last few years, but that’ll flare up again with a layer cake.

Prof Pete Smith: [00:10:04] So if people are stressed, poor sleep, these types of things can make hives get worse, like pain. If we have poor sleep, pain scores can increase by 30%. When we have poor sleep each course go up. If we eat foods that are high in chemicals between 30 and 70% of patients with high scores become worse. 

So why those co-factors is it’s important to know about them and they give us great opportunities to improve the condition until the body’s there’s not a threat going on by getting those right. And that’s part of the joy of unravelling that and also communicating that to our patients.

Dr Ron Ehrlich: [00:10:44] Yes. And yet Australia, you mentioned Australia has got one of the highest rates of allergy and asthma. Yeah. And why? Why is that so?

Prof Pete Smith: [00:10:54] I’d say it’s a land of plenty and pretty good self-indulgence we’ve got. And this is purely speculative with, with the Western world guys with we and the UK and the US all look pretty similar. We have taken on ultra-convenience of fast food, ultra-convenience of being indoors, watching TV, and not exercising. 

I certainly published on, we have more advanced glycation end products which are products that form when you cook sugars at high temperatures, the super high temperatures, they look like compounds that are bodies near the same before, but then mimic and look identical to the compounds that are released from damaged tissue. So these are called advanced glycation end products.

Prof Pete Smith: [00:11:46] So intense glycation products look very much like alarmins, which is peaking on called HMGB1 the high mobility group box 1 protein that gets released from damaged tissue and tells the body, “Hey, we’re in danger, and that can cause mass cells to regulate. It can cause nerves to be sensitive, it can put cells on high alert and be protective. So allergy is probably self-protection gone wrong. And we have repeated stimuli. We have amplification of the disease process. 

We have lots of things that interfere with our homeostasis. If we’re looking at food allergy, we’ve got ideal homeostasis, eating a wide range of natural foods, less sugar. We know that a human can’t take more than 4 to 6 grams of fructose at one time, and that’s with fibre. That’s with all its natural flavonoids and antioxidants that go with it. 

You juice it so they will disappear and you have an overload even though it’s healthy. And so we’re having a lot more sugars as well, which can form these compounds. We’re cooking at microwaves and frying stuff, so the human body hasn’t seemed to be prepared in that manner before and mimics that. 

Prof Pete Smith: [00:13:07] We’ve got irritants in the airways pollutions. We know diesel exhaust particles plus allergens can amplify allergic responses and promote an allergic response. We’re seeing microplastics appear in our airways, in our food, and even in our bloodstreams. So they will cause irritation. 

We need bacteria. Bacteria reflect what we eat. So bacteria diversity, the types of things we put into our diet, we have inflammation that occurs after we eat a meal. And I know you’ll be very aware of the oral microbiome, and that’s certainly a summary that hasn’t been really explored in food allergies plus the focus has been on the gut and the talk that goes between it. But we’ll touch base on that as well.

Dr Ron Ehrlich: [00:13:51] Please do. I mean, yeah, the oral microbiome in terms of the gut. Talk to us about that. 

Prof Pete Smith: [00:13:57] So it’s a place with foods get seen very, very quickly and we rely on an intact epithelium there and sensation. So the mouth is very highly innovated and has got lymphoid tissue in the tonsils there to recognise and react. And we’ll use that route to decentralise people say with sublingual immunotherapy, but very little is been studied on the oral microbiome compared with the gut microbiome. 

But the more we eat, the more been to this diet, eating the rainbow, eating leafy green vegetables, you get a preferable gut microbiome. There are some herbs and plants that improve that. We know that eating rubbish food surprisingly can make it worse. Antibiotics and acids can change that around and ruin some of their own defences.

Dr Ron Ehrlich: [00:14:53] And another area that we focus on a lot is mouth breathing and nasal breathing. And that’s got to set us up for allergies just there alone being a predominant mouth breather and it’s so common. 

Prof Pete Smith: [00:15:06] I’ll get back to that but I’ll take this but one sec about the mechanisms because our bacteria has to communicate. We’ve got quorum sensing receptors that pick up the danger and we’ve got a range of compounds in process food. We’ve got emulsifiers, we’ve got detergents that are left on plates. Even after washing that one part per million can interfere with the bacteria talking to the gut lining. We need to have bacteria to tell us that we’re alive. 

In sterile animal studies done in The Lancet 1966. Rats. So mice, it was rabbits brought up in a sterile environment basically developed anaphylaxis with feeding. Pseudo has a Japanese study of shown similar with mice born strong bombs towards allergic responses. But we need bacteria to tell us things are okay and we have a barrier with emulsifiers, things that make as our butter-smooth better that make our toothpaste work better. 

And you see what I’m getting? So ice cream scoops better. So we have emulsifiers carrageenan, which creates a film surfactant and we have surfactants detergents that actually stop the bacteria talking to the lining. And hence with animal models, it looks like that’s very important. What’s the point of having good gut microbiome if we’re not getting… able to talk to the epithelium and the immune system beyond that.

Dr Ron Ehrlich: [00:16:31] Gosh, you talk about cooking methods, setting us up for compounds that we’re not familiar with, but the number of chemicals that are going on in our world is just growing exponentially. It’s actually when you talk about all these things, Pete, I’m amazed. I was shocked initially at 20%. Wow, that’s a huge number. But when you talk about all the things that contribute to it, you think how on earth, we must all be allergic to some degree, whether it’s clinical or subclinical. 

Prof Pete Smith: [00:17:02] We’re resilient. It’s amazing. We’re still here. But look, that’s a whole different. I’m hesitant to use the word ball game, but mouth fertility was certain sperm counts have dropped by 50% in the last 40 years. So something’s going wrong there. So something in the water and our bodies are saying it’s not right.

Prof Pete Smith: [00:17:23] So going back to the oral microbiome, we’re sort of seeing reflux disease, not Barry Marshall as you’re aware, identified Helicobacter as a factor and this is passion to turn off stomach acid because we can. Stomach acid is important in breaking down food proteins. In animal models which are very hard to create in animal models, food allergy without turning off the stomach acid.

Dr Ron Ehrlich: [00:17:46] Interesting.

Prof Pete Smith: [00:17:47] We’ve got very good at doing that in the last 30 years. It also in the last 30 years, our fructose consumption has gone up by 700%.

Dr Ron Ehrlich: [00:17:59] What?

Prof Pete Smith: [00:18:00] So it’s a cheap flavouring and that very much parallels our rise in food allergy in young children. It’s a great superimposed graph so eating clean would seem a very sensual idea.

Dr Ron Ehrlich: [00:18:20] Yes. Well, I know that antacids, it was a multibillion-dollar industry and I think when you factor those in with over-the-counter ones with the prescription ones it’s setting us up for you said without stomach acid, we don’t we’re less susceptible to allergies. So, you know, here we are trying to switch it off all the time.

Prof Pete Smith: [00:18:43] It looks a bit circular as well. These are drugs for the short term use for acid suppression. We certainly don’t want acid spilling up and causing what we called Barrett’s oesophagus, where we can get chronic erosions and cancerous change with reflux up until the nineties, we’re doing operations in these patients. But we give long term acid suppression. 

We can get micronutrient depletion. We need acid to digest. We also so we take the microbiome, we get depleting magnesium and magnesium and melatonin, two of the most common indulgent compounds that actually tighten the oesophageal tone.

Dr Ron Ehrlich: [00:19:24] Interesting.

Prof Pete Smith: [00:19:25] So you’ll actually set yourself up for reflux by treating your acid suppression. The Canadian Gastroenterology Association has talked about osteopenia when you’re using these products more than several years. We do have a metaplastic change. We see more interchromosome cells appear in many stomachs after years of using these proton pump inhibitors. 

And safety of these really has not… Long term safety hasn’t really been established in children where they get used, and certainly not in under two years of age. We’re getting a few screams, you get reflux. I think we’re going to see a revolution in a tide against them as there’s more and more evidence of their potential side effects like we have seen in steroids in the last five or six years. 

We used steroids around everything but if we look at the data for long term accumulation with some risks of osteoporosis, cataracts, heart disease, kidney disease, and it’s this exponential just stacks up. The more that you’ve had it. That’s gonna one gram of steroid over eight years, which is four causes that you might treat for asthma.

Dr Ron Ehrlich: [00:20:40] It’s interesting to hear you talk about the oesophageal tone of a muscle tone because we had a guest on Dr Pran Yoganathan who talk about reflux being a reflection of diaphragmatic sarcopenia. And I thought, wow, interesting. Particularly when coming back to the breathing. If we shallow breathing, mouth breathing, we’re not engaging our diaphragm. You know, there’s another factor on top of all the foods and everything we’re doing.

Prof Pete Smith: [00:21:09] That might tighten it up and close that valve. Going back and I’m saying what we’re talking about is a very tangled Gordian knot. One breaks into the other. 

Dr Ron Ehrlich: [00:21:18] I think it’s called the human body, Pete.

Prof Pete Smith: [00:21:20] Yeah, it is. Mixed physiology. And there’s not one thing. Again, it’s an exciting part of unravelling and trying to explain it. But yeah, all things are not linear as you know. The oesophagus normally should have PH less than 4. And when we say reflux out there, it’s indicative of the condition level, things like let’s treat that. But we actually have published something about all 15 months ago, 15, 16 months ago where we actually looked at baby foods and we found half of these pouch foods had a PH less than 4.

Dr Ron Ehrlich: [00:21:54] Wow.

Prof Pete Smith: [00:21:55] Babies are swallowing foods that will have a PH which is known to injure the epithelium and they’re eating this stuff. Fortunately, I think the oesophagus below, once you get into the oesophagus, it does actually have bicarbonate glands which can help neutralise the acid. But that remains a sort of an underexplored area of possible injury. 

And my take-home message is these pouch foods don’t encourage chewing direct… Encourage that one on the jaw. I would say kids get small jaws and not chewing. We’ve also seen underdeveloped one of the joy from mouth breathing as well and we’re seeing people in their twenties with sleep apnea. 

Their tongues too big for them, for their jaws. With reflux as well. When you give a proton pump inhibitor or antacid in any form, they stop the acid. They do not stop pepsin.

Prof Pete Smith: [00:22:51] Now, pepsin is a digestive enzyme, kind of like you might put papaya if you find that like your meat tenderizer. It’s an enzyme that digests and that comes up with reflux to the throat, to the tonsils, it’s the mouth, the teeth that’s found in the middle ear, the sinuses. So that is still there. And it can stick in the tonsils and digest the why and cause inflammation. So that doesn’t degrade. 

And a lovely study was done in 2017 which showed a Mediterranean diet, which is 90% plant-based. You’re more fish, you’re sort of a blue zone type lifestyle. And stress can be a factor in gastric motility as well. But in this study, they looked at diet and gargling alkaline water. So Pepsin doesn’t degrade and PH is about eight. 

So gargling a bit of alkaline water will worsen colds, can degrade pepsin and becomes less of an issue and they showed that was as effective in oropharyngeal reflux where people get heartburn up and burning the back of the throat as a proton pump inhibitor.

Dr Ron Ehrlich: [00:24:01] Mm hmm.

Prof Pete Smith: [00:24:03] More natural. And I’m keen for that as a treatment, as a replacement. If people are getting oesophageal heartburn that need to be monitored and kept in check. I don’t ever want to cause a case of cancer with saying, look, I’m not that keen on PPIs, but with any medicine, you’ve got to look hard. Do I need this medicine? Can I do other things? Can I change the amount of coffee, the stress I have in my life, the things that are making my body want to turn acid on?

Dr Ron Ehrlich: [00:24:34] Hmm. Hmm. There’s also I mean, we’ve explored also on the programme recently, silent reflux and paresis of the laryngeal muscles going back to infections that could have gone on years and years ago. And that’s a whole other ballgame as well, isn’t it? I mean, and as the name implies, often undiagnosed.

Prof Pete Smith: [00:24:58] Yes. Reflux can increase sensitivity of the larynx. And up to 30% of patients with asthma don’t actually have asthma. And as you’re talking about the episodic paralysis of the vocal cords, which is called intermittent laryngeal instructional vocal cord dysfunction, was goes back to about 1993. 

The first description of that where it was actually five women, where they had reports of getting bouts of sudden spasms of their voice and difficulty breathing. And the thing that helps us differentiate that from asthma is that patients with that cord dysfunctional ILO will get this come on suddenly. Whereas asthma can build it up a little bit. It doesn’t respond to Ventolin. Tightness is here rather than the chest. The difficulty is breathing in rather than out. And 40% of patients with asthma can have an aspect to vocal cord dysfunction. 

And the more we use the bronchodilator, we can actually relax with muscles in our lungs, but also our laroesophageal sphincter. So when you’ve got asthma, your diaphragm are pushed down as it goes up. And if you’ve got TCD, you’re creating a suction pressure and you suck it up. 

So our treatment of that is we the fact that if it turns into middle, it usually means there’s nothing wrong structurally. Speech therapist and ENT surgeons can have a look down with flexible scope and have a look at the larynx, the treatment of it. And you might get patients in the chair in dental surgery with strong smells or reflux and lying down can actually induce. And the trick with that is to get the patient to relax glass of water from the shoulders and diaphragm to focus on breathing and go sip sp sip in a second. 

Whoa, whoa, whoa, whoa. And you see 5 to 7 breaths that disappears. [Inaudible 00:27:02] doesn’t work. It doesn’t help that condition. So it’s simple breathing exercises. If people want to have a look at that, they can look at TCD and ATS, the American Thoracic Society. They’ve got a two-page information sheet.

Dr Ron Ehrlich: [00:27:13] And the condition, again, for our listener.

Prof Pete Smith: [00:27:15] Is called intermittent laryngeal obstruction or vocal cord dysfunction. It actually has the unfortunate name, which has been attributed to it as Globus Hystericus, which means a hysterical feeling of something stuck in the throat because it really does feel like something is there. I’ve had patients come in with this, they will sort it out thinking they’re going to be dying from it. 

Usually what happens is they do, relax and start breathing again. And the visualisation that I do when I’m explaining these to people is think of your airways like a wet rabbit shoe. Like bicycle type. It’s gone, stuck together. If you try and do a big hard breath through it, it’s going to be hot. But if you do a little three sips, they can get off the air so you won’t have air hunger in. Breathe out. Oh, oh, oh, and then breathe it away. Practise it so that you can actually deal with it should be the emergency card.

Dr Ron Ehrlich: [00:28:11] Wow, that’s so cool. I’m you know, and you talk about bronchodilator I know nitric oxide is one of the body’s most potent regulators in that way, is it not? 

Prof Pete Smith: [00:28:25] It has racks definitely [Inaudible 00:28:27] effects as well. 

Dr Ron Ehrlich: [00:28:29] Which we did we did a programme with someone who’d done a PHD. See, Pete. This is my indulgence, Pete. I get to ask people like you questions and they know so much more than I do and you answer them and I learnt more. But he was a PhD in breathing who said something to me that 60% of the body’s nitric oxide is produced in the paranasal sinuses. Only when you breathe through the nose.

Prof Pete Smith: [00:28:53] And that is it the sinuses are not blocked. And this is an area where they actually I’ve shown that treatment with medication or treatment with surgery both leads to that and now he’s got anti [Inaudible 00:29:11] so it is important in maintaining that tone maxillary sinus. Can even be produced in the upper pharyngeal airways. 

And as far as working breathing 20 to 30% of the ether breathing is through the nose. It’s a magical organ and when it works fantastic, when it doesn’t work, it becomes the centre of the universe and it warms through these humidifiers. It takes it and responds to stress, which is what causes the phenotype of rhinitis, whether it be allergic or this other. 

Well, these are the common ones and less common forms of rhinitis. So one in five of the people watching this podcast will have sneezing with sunlight, which is called photic sneezing, for example. It’s 80% Caucasian population, the most common autosomal dominant condition in Caucasians. 

Dr Ron Ehrlich: [00:30:02] Sneezing with sunlight.

Prof Pete Smith: [00:30:04] Yeah, it’s called ACHOO (Autosomal Dominant Compelling Helio opthalmic Outburst Syndrome) and there’s a great Wikipedia summary on it. And it was originally described by Aristotle.

Dr Ron Ehrlich: [00:30:15] Wow.

Prof Pete Smith: [00:30:15] So that’s part of the oldest reference I have in my years ago. Yes, he actually had the condition himself and he thought it was the sunlight warming up the brain, the humus of the brain. Thomas Bacon. Back in the 1600s, English philosopher, worked out, again, he had it as well. If you walk out to the sunlight with his eyes closed, he didn’t he didn’t get this.

Dr Ron Ehrlich: [00:30:37] Just what is that mechanism again? That… 

Prof Pete Smith: [00:30:39] It’s photic sneezing. So it’s the light that hits the eyes and the trigeminal nerve has an innovation that goes through the eyes with the conjunctiva, but also the nose. So we learnt in medical school and in dentistry school that we simulate a nerve there’s an accent reflex. There is, but there’s also the polarisation of those instruments and release of neuropeptides locally. 

So along with that whole area of the general nerve you get neuropeptides released. So it can hit there. We can pick up the sunlight and bang neuropeptides get released and we can sneeze. And some people are more sensitive that to others.

The same as smells rapidly induce migraines and temperature changes because the tribunal nerve goes here, goes back and also receives information from the meninges and depolarisation and dies in those neuropeptides and cause vasodilation and headaches, which is the strong smell, like a protein or volatile organic compounds.

Dr Ron Ehrlich: [00:31:39] Mm hmm. Wow. This is, that’s fantastic. Chronic pain we’ve touched. We just chatted briefly about it yesterday, and now it’s not a… But chronic pain is an interesting one. And you were talking to me about that trigeminal nerve and the excitability of that nerve. And can you just share with us a little bit about that again, for me, I just thought that was fascinating?

Prof Pete Smith: [00:32:04] There are a couple of ways to go with this. The one that we talked about was rhinitis and hypersensitivity of that crossed over with a condition called non-allergic rhinitis where we had sensitivity to the trigeminal nerve and chemical receptors. We do see overexpression of a molecule called TRPV1, which is the transient receptor potential vanilloid one receptor.

It’s pretty exciting and more cool because David Julius was awarded the Nobel Prise for his discovery of that in 1997 he got the award on October 4th last year. And this is a very important pain receptor, and it’s upregulated in patients with allergic rhinitis. It was [Inaudible 00:32:47] rhinitis. It is upregulated analogy. It’s upregulated in reflexes, upregulating asthma. 

But it’s got a twin called TRPA1 which is where a drug called acetaminophen or paracetamol which we didn’t know until 2011. So we’re using it all these years, so paracetamol tells that and that’s a cool channel receptor, but it’s got a very promiscuous tail. So it picks up a lot of chemicals like volatile organic compounds, [Inaudible 00:22:19] and protein in smoke. 

It picks up things like allicin, which is in onion, part of making us cry. Wasabi, horseradish, mustard. So why your nose is smart. When you have a bit of get a wasabi here, it’s overstimulated TRPA1 and causing a release of neuropeptides. And that’s happening to your nose, in the mouth because the trigeminal nerve is at the top of your palate and that’s causing that whole androdomic release in your eyes and nose. 

So that’s just showing you how your nerves can get excited from one side and before it will swell. I’m sure everybody can write to mustard or wasabi if it’s the same receptor. One does have a little bit of that’s a burning pain for chilli. So we use capsaicin patches to fatigue that, but we can also use capsaicin in non-allergic rhinitis.

Prof Pete Smith: [00:34:08] And you were interested to hear all the triggers for non-allergic rhinitis which can be found in a nice 2009 review by Jonathan Bernstein in the World Allergy Organisation on the characteristics of non-allergic rhinitis. But these are irritant triggers and many patients with allergy will have them as well, but may not known and some have the exact phenotype as allergy or have a skin quick tester and now you don’t have allergies, but it looks exactly the same. 

And those type of triggers are perfumes, hairspray, fly spray, deodorants, incense, gardenia, jasmine, oranges, lilies, cold air, airconditioning dropping temperatures often 6 to 8:00 at night, 2:00 in the morning, frozen food in supermarkets, cigarette smoke, bushfire smells, burning old smells, cleaning hours. These are fumes not polished used by print, paint surfaces, chlorine, bleaches, glues, soap shops. And we’ll see patients like these often with sulphite sensitivity. 

The 220 to 228 in be one sided champagne dried apricots, sundried tomatoes, sausages, pickles, and prawns. And on the Cincinnati Irritant Index Scale they also had artificial Christmas trees, now turpentine, kerosene, sawdust, smells of malty grasses, which can be irritants and have lots of files which can protect these receptors that pick up the danger.

Dr Ron Ehrlich: [00:35:28] Pete, I’m glad I recorded that because I was so impressed when you said that to me yesterday and I actually hearing it again now, I just thought, well, how am I ever going to get that on the transcript? I feel we’re going to get it on the transcript. That’s going to be good.

Prof Pete Smith: [00:35:41] Yeah. 

Dr Ron Ehrlich: [00:35:43] What’s the state of the… I remember when I was growing up, there used to be these scratch tests, you know, and is that what’s the state of the art of allergy to in 2022?

Prof Pete Smith: [00:35:55] Look, the beauty of scratch testing or skin prick testing. We don’t scratch, we’ve got these standardised lancets that pick up a little bit of the allergens and deliver a very standard point to of allergens in your skin. And we use the pre standardised allergens so if I had a skin practise here in Queensland and I do the skin tests, it would deliver the same results as somebody doing in London or New York. 

So those are relatively standardised but they have their limitations like for somebody with Kiwi allergy or latex allergy, a lot of the allergen that does fall are fairly laboured breakdown or when we bottle them, they degrade. So that’s the beauty of doing a fresh food, skin prick test. So they have great utility. We can do a range of them and get the answers within 15 to 20 minutes. For a blood test that means get drawing blood. 

The government and Medicare limits it to about three tests at once. So if somebody’s worried about what might be causing them allergies in the environment, doing three tests doesn’t really leave a good bit of much as far as opportunity to go and see what the causes are. So they can get repeat blood tests from multiple test multiple times. But it’s part of austerity. You can get a private panel which can look at many of these at once. 

And some of the pathology likes do this in the range of 380 to 500 dollars to look for a wider range, which is important if allergies interfere with your life you don’t want to be spending $50 a month on antihistamines, which, by the way, only improve rhinitis scores by 7 to 8%. Despite what the TV ads say in screens. You want that because it can affect your quality of life. So we do want to know.

Dr Ron Ehrlich: [00:37:40] So I’m part from, you mentioned the blood test and I remember years ago having a blood test with a panel of 270 different foods. And they came back and, you know, they graded I ended up with eight foods that graded on a 1 to 4 scale of my level of sensitivity. And that’s a valid, a good test to be doing?

Prof Pete Smith: [00:38:02] I’d say no.

Dr Ron Ehrlich: [00:38:02] Okay. No, that’s good. I don’t mind hearing that.

Prof Pete Smith: [00:38:06] The IgG4 testing we actually have IgG4 as a tolerance anyway. And there is this form of testing which is available in Australia. It remains to be validated through IgG-mediated food down where people get hives and swelling. We tend to make IgG4 and we encourage IgG4…

Dr Ron Ehrlich: [00:38:28] Let me just stop you because IgE was immunoglobulin e and IgG is another immunoglobulin. I know it and I know what it was, but I just for the sake of my listener, I wanted to be sure they knew what we were talking about. 

Prof Pete Smith: [00:38:41] We have tolerance antibodies. Tolerance antibodies include immunoglobulin A and immunoglobulin G4. Then, there may be going special in that they don’t have tails that activate the immune system. So complement activating tails so they neutralise foods. And if we don’t eat them, they fall off. So you might have to add in so many things. 

You’ll see these you’ve got good amounts of IGG4, change your diet, lose it the next time you eat, you’re going to feel sick because you’ve lost your IgG4 because your body doesn’t see it. And interestingly, it IGG4 has this recycling mechanism, it’ll go to the need to mop up that antigen or allergens and gets recycled depending on my PH gradient in the duodenum, which is influenced by the PH of the gut and also the guts we can lose that PH rating as well. 

I was very hesitant to use the term leaky gut because it was a term that other people would talk about outside mainstream medicine. But it’s been shown that the term increase, epithelial permeability.

Dr Ron Ehrlich: [00:39:47] Intestinal permeability, I think.

Prof Pete Smith: [00:39:49] The nature’s using the term leaky gut in general. So that gives some validation and pioneer to people that was like this doesn’t make sense. We know that the gut is leaking, but we… So mainstream thinking more in that line. We know that stress can affect gut permeability. We know that pollutants can affect gut permeability something that said microplastics. 

The chemicals that we’re seeing with carpet cleaners, for example, where a body doesn’t know how to get rid of them. You talked about the importance of the nose. The nose will make 500 millimetres two litres of mucus a day, which ends up in the stomach. But what’s in there is the trapped environmental irritants and pollutants. So diesel exhaust particles, which not we know you’re trying to solve and getting out in the environment, has been shown to be healthy. So we sample the gut microbiome, both for our lungs and for our gut.

Dr Ron Ehrlich: [00:40:54] This may be seem like a really basic question, but I’m going to ask it anyway. What’s the difference between an allergy and an autoimmune condition, or is an allergy an autoimmune condition?

Prof Pete Smith: [00:41:04] The allergy autoimmune is when we attack ourselves, so most allergies is autoimmune. So it’s actually something that’s outside ourselves. We do have autoimmune allergy with chronic urticaria where we get hives and swelling and oedema, and that’s often associated not often very 18 to 22%, I think it’s estimated. 

People have an IgG attack on their thyroid and there’s one of the little organelles inside cells called peroxisomes, and that’s one that we make a lot of antibodies in autoimmune thyroid disease. We make many patients who get quite spontaneous that we carried a sign that the IgG response is going to join the party and then IgG responses to peroxisomes. 

Another common side is that we make IgG to in chronic spontaneous ed is interleukin 24, which is a cytokine we often see in high concentrations at the base of the epithelium bottom of the skin there. And that seems to have a role in melanocyte function and regulation of those cells. It’s a target, the body attacks it and we end up getting high to the swelling the course of our body, making cytokines attack themselves.

Dr Ron Ehrlich: [00:42:15] Hmm. And when it comes to treatment, I mean, apart from avoidance, I guess that’s the best… Is that the best treatment?

Prof Pete Smith: [00:42:26] With any disease, Ron?

Dr Ron Ehrlich: [00:42:28] Yes. 

Prof Pete Smith: [00:42:29] Doing the detective work. If there’s a fire, stop talking fuel on it.

Dr Ron Ehrlich: [00:42:33] Or even allergic to what they would consider to be healthy foods?

Prof Pete Smith: [00:42:39] Yes. Again, let’s go back to the whole body story that I’m sure many of the guests have resonated. Yes. Get your healthy sleep, get your good nutrition. Make sure we are not micronutrient deficient. We haven’t had a good volcano in Australia for 20 million years. So some of those micronutrients are just not in our food sources and the way that we eat, even if we’re eating healthy and it can be an issue, make sure your body knows it’s alive and exercising. Make sure the danger receptors go up. If we don’t exercise, it thinks we’re in danger. 

Body tries and helps ourselves. Make sure your headspace is right. And also, as you saying, breathing. The nose, getting back to the nose, it warms thought is humidifiers. It’s spectacular. It will take a 40-degree temperature or a-five degree temperature and turn it back to 31 to 32 degrees at the back of the nasopharynx to enter the lungs in this nice, comfortable manner. It will end up being 90% humidified. 

So and it will have these chemoreceptors that pick up chemicals and danger. And if there’s something irritated, whether it be an irritant or an allergen, it’s got responses that will make mucus to trap that to sneeze it out to you, get away from your infection. And when things go wrong, that’s when we have symptomatic disease.

Prof Pete Smith: [00:44:03] I should say. Avoid exposure. Our medicines are Band-Aids. My job is to get the people the best band-aids to work out what to avoid. And we do have the luxury of the analogy of identifying what people are allergic to. Have been doing immunotherapy for more than 110 years. 

Groups in St Mary’s were doing this in around 1910-1911 and giving people injections of pollens that they collected in under the skin. And without all the danger molecules in the epithelium saying, “Hey, there’s a problem here.” The body saw it as something that they was part of itself and would make these protective antibodies, particularly, as I said, IGG4 which is quite soluble. 

It would move to mucosal surfaces and when you breathe in that it would mop it up kind of like a molecular sponge. Some would get to the core symptoms that we see in 2022 using immunotherapy as a very good treatment. It’s sort of the gold standard for somebody with allergic disease and will most commonly do that to dust mites and grasses, but also animals and animal allergies as well.

Dr Ron Ehrlich: [00:45:15] And with a good degree of success with that?

Prof Pete Smith: [00:45:17] Look at the success rate. If you pick the right patients, 85% patients getting a really good response. And you know that in the first six months of treatment. If we sit them in a room and put it through the gas chambers, like the vienna chambers they used to test allergies, they can detect the difference in about eight weeks. We think we using tissues in the wake of the wider institutions and people touching the nose as people subjectively find that 4 to 6 months that we see that improvement and the improvements, depending what the scales you use, 40 to 70% reduction in medication and symptom scores if you’ve got the right mixture. 

So good improvement if you’re looking at antihistamines, you’re looking at 7 to 8%. If you look say a simple nasal spray like Nasonex you would get 20% improvement going to look at 40 or 50% improvement in symptoms, which is a combination of an antihistamine and a £9 steroid nasal spray. But again, good bandaids. And with immunotherapy, if you reduce the medicines, if you still need them, they work better because you’ve got less inflammation. 

So and we do immunotherapy the 3 to 5 years. I generally get a good result with three years because they’ve become so stable now. They used to be sort of water-based and still are. But in the newer forms, you can get up to top dose in four weeks. So we used to have to do it up swelling so over four months… 

Dr Ron Ehrlich: [00:46:44] …and it’s a continuous treatment over those 3 to 5 years. 

Prof Pete Smith: [00:46:47] Yeah, it’s monthly. It starts at least once we establish five days. Many of my patients, I get top dose between one day or four weekly injections of which we have to cut dose. And we assess and in the first 6 to 12 months to make sure that it’s working well for them. And if it’s not, we want to work out why and it goes down when we let them do the three years and they have a trial of it.

Dr Ron Ehrlich: [00:47:14] Gee, Pete. We’ve covered so much territory here. I had my head is spinning. I’m going to be listening to this again. I know I will because there’s so much that we’ve talked about. I just want to finish up. I want to take a step back now and finally and just ask you this question, because putting aside your role as a doctor, researcher, or a teacher, we’re all on a health journey as individuals in this modern world. What do you think the biggest challenge is for people on that journey?

The Biggest Health Challenge

Prof Pete Smith: [00:47:44] I think we’re living in a period too convenient. Well, we’re too comfortable. It’s too convenient to eat clean. Too convenient to sit down and watch TV. Too convenient to actually live where many of us get into the trap of existing and not putting effort into having quality of life. And we do that and think a little bit about what we’re doing and why we’re doing it. Metacognition is one of those skills that we get thinking about how we think and what we do as we get older. Getting old sucks, but we should get smarter over the way and enjoy the journey more.

Dr Ron Ehrlich: [00:48:20] Well, as far as I know, getting older is still the best alternative. And thank you. Thank you so much for joining us today, Pete. I really appreciate you sharing your wisdom and knowledge with us.

Prof Pete Smith: [00:48:31] Thanks. My pleasure. Absolute joy to be here and joy to share that and get a chance to have a chat with you. So thanks very much, Ron, and hope your listeners enjoyed it.

Dr Ron Ehrlich: [00:48:39] Thank you.

Conclusion

Dr Ron Ehrlich: [00:48:42] Well, there is another piece of the puzzle looking at the body as a holistic thing, which it is, of course. And when we talk about specialists, be they gastroenterologists or respiratory physicians or speech pathologists, cardiologists, we come to realise that we and we are reminded of the fact that we are dealing with a whole human being. 

And as Pete alluded to, the world of allergy treatment. If you approach it in the way that he has and he does, then that is really looking at the whole person. That’s the only way to interact. It’s the only way to identify what is predisposing an individual to a problem, what those problems might be, and importantly, how to build resilience back into an individual. 

And we come back to the five-pillar model of sleep, breathe, nourish, move and think. It’s not rocket science as the world we live in becomes more complicated. I truly believe the solutions are remarkably simple and accessible and cheap and effective. 

So this was just a wonderful conversation, which I’ve been looking forward to for some time. Check out the transcript. There’s a lot in this one that you will want to read, and we’ll go through that very carefully. I hope this finds you well. Until next time. This is Dr Ron Ehrlich. Be well.

This podcast provides general information and discussion about medicine, health, and related subjects. The content is not intended and should not be construed as medical advice or as a substitute for care by a qualified medical practitioner. If you or any other person has a medical concern, he or she should consult with an appropriately qualified medical practitioner. Guests who speak in this podcast express their own opinions, experiences, and conclusions.