#96 Healing More Than Allergies With Dr. Atul Shah

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Transcript Disclaimer:
This transcript was generated using AI software from the original podcast audio and may contain errors, omissions, or minor inaccuracies. It has been lightly edited for readability. Please refer to the full podcast episode for the most accurate representation of the conversation.

Atul Shah, MD 0:00

If I ask you what's the definition of anxiety, you probably will say, it's where they have some related thought process that is faster than the mind can handle. Now, it basically it's an overactive mind, right? Now, when we say what's an allergy? Allergy is an overactive immune system. Now we have something that's mind related, and you have something that's immune system related. if you can desensitize immune system for the food allergy they have, why can't we desensitize the mind where they have overactive mind?

Amanda Whitehouse, PhD 0:33

Welcome to the Don't Feed the Fear podcast, where we dive into the complex world of food allergy anxiety. I'm your host, Dr. Amanda Whitehouse, food allergy anxiety psychologist and food allergy mom. Whether you're dealing with allergies yourself or supporting someone who is, join us for an empathetic and informative journey toward food allergy calm and confidence.

All season long here on Don't Feed the Fear, I've been bringing on guests and trying to have conversations that help you not just understand and feel more confident about navigating food allergy treatment decisions, but that show you that treatment isn't only about changing what the immune system can tolerate. It's about helping you feel differently about your body, your food, your future, and your own sense of possibility We've taken so many angles. We've explored OIT, SLIT, TIP, biologics, patient experiences, parent experiences, and the reality of living through treatment and the emotional and psychological layers that can come with it. So as we wrap up the season, I wanted to end with a conversation that brings many of those threads together.

Today's guest is Dr. Atul Shah, a board-certified allergist, immunologist, and the founder of New York Food Allergy Wellness. Dr. Shah's career has been deeply connected to the development and evolution of food allergy treatments like OIT and SLIT. His FATE program or Food Allergy Tolerance Enhancement brings together the medical perspective as well as consideration for the whole patient and family who are sitting in his office. I hope you'll enjoy this conversation about what is possible when medical treatment and psychological healing are considered alongside one another

Amanda Whitehouse, PhD 2:15

Dr. Shah, I'm so honored to have you here on the Don't Feed the Fear podcast to wrap up our last episode in our season on allergy treatment options and immunotherapy. Thank you for being here.

Atul Shah, MD 2:27

Thank you, Dr. Whitehouse, for having me. I know you have very successful podcasts. I know a lot of people benefit out of listening to you.

Amanda Whitehouse, PhD 2:34

Thank you so much. I have been following you and your work and your colleagues' work for many years. But for those who aren't as nerdy as I am about food allergy treatments and immunotherapy, could you give people a little bit of info on your background and then developing your program and your approach to food allergies?

Atul Shah, MD 2:52

Sure. So commonly people ask me, do I have food allergy? Do I have family member with food allergy? And the answer is no. But I think my patients helped me to get interested in this space. So I'm a board-certified allergist. Initially, I was doing general allergy, then food allergy became my passion. And now I'm considered one of the visionary or pioneers in the space, and we take the advanced science and apply it to clinical practice. That's my strength. So I founded New York Food Allergy and Wellness, and we provide, uh, clinical care to infants, children, adults from all aspects of proper diagnosis to treatment, ultimate goal is quality of life for them.

Amanda Whitehouse, PhD 3:37

The overall picture, that I understand from what you do is exactly what you just touched on. It's individualized treatment. It's not necessarily a rigid protocol or the same goal for every patient, but really improving their quality of life and whatever that might look like for them, right? So let's start there in terms of what you see from the people you work with and what success means for people who are coming in with food allergies.

Atul Shah, MD 4:01

So it's interesting that patients with food allergy have different perspective on their own allergy. so, you know, clinicians, physicians, when they see the number, they think, "Oh, okay, numbers are same, so two patients may have the same need." the needs are very, very different. child or an adult with food allergy may be happy with the quality of life they have, and they may just want to be safe, and there are ways we can keep them safe. There are children and adults where they really want to have complete freedom. They want to have quality of life. They want to go to Yankee game and have, uh, Cracker Jacks there, or they want to travel the world and not worry about, uh, looking at the labels. So for me, success by definition is actually what I use for my own, own success. I read a quote, I believe it's from Wayne Dyer he said, "Success means progressive realization of worthy goals." Again, I'm breaking it down. It's a progressive realization of worthy goals. So if you apply that to our food allergy patients, if you help them to get to their worthy goals, what is meaningful to them, and if you help them realize progressively, I think we, we're kind of taking them to success. So in my mind, success for every patient is different and we allow them to make the decision

Amanda Whitehouse, PhD 5:18

I like that emphasis on the progression because I know with my own son's experience and many of the clients I work with, the goals change as you progress through treatment. And some people who thought they only wanted protection might aim higher depending on how things are going, and the opposite, right? "Oh, actually, I don't want to eat that." Do you see a lot of change as people are moving through in that same way?

Atul Shah, MD 5:38

Yes, th-that's very correct because see, again, we know that go as far as you can see. Once you get there, you'll see it further, and that's what applies to life. We don't know what tomorrow holds, but if we can tell them where they are, what potential they have, where they need to begin, and what's possible, then you allow them to start the journey, and halfway through the journey you say, "Oh yeah, I can go further. I can go further." And those who decide to go to safety may choose to go to free eating and vice versa. Someone wants to go to free eating, halfway through this, it's too much for me and I, I don't want to continue. But at least you help them to get to what, your freedom they have.

Amanda Whitehouse, PhD 6:18

Probably a big part of that is a topic that I know you and I are obviously both passionate about, but is the psychological aspect of that, right? So some of it is the medical goals that are realistic for someone, but some people have so much anxiety or trauma symptoms from their allergies that I would think that would determine a lot of their starting point and then where they end up progressing to. I would love for you to talk about how you approach that in your treatment, and I know this is a really essential part of your care and your program.

Atul Shah, MD 6:45

You know, we look at a patient as a person. Yes, on paper, patient is a patient, but then they're also human beings. They all have all the needs that we have, and if we focus only on their immunological desensitization, that's what most treatment does. We're missing out on the larger picture. So sometimes asking them direct question, you are, what do you want to do? What do you want to achieve? And sometimes the goals are very, very simple. Sometimes they'll say as simple as, "I want to have a slice of regular pizza." think of a child with milk allergy, and their life goal is actually to have a slice of pizza. And do we have science to get them there? Absolutely. So why not to help them achieve their goals? At that point, immunological desensitization is important, but helping them get through the stress of having milk allergy and getting to on the other side is what I call a psychological desensitization. I know you were at a FAST meeting, you used that word, and I loved it. 2018, I was teaching around 42 allergists on how to do desensitization, and that's when I had used that word for the first time. And I love it because it, it's a desensitization that's needed. Like if I ask you, you're a psychotherapist, you are an expert in this space, and if I ask you what's the definition of anxiety, you probably will say, it's where they have some related thought process that is faster than the mind can handle. Now, it basically it's an overactive mind, right? Now, when we say what's an allergy? Allergy is an overactive immune system. Now we have something that's mind related, and you have something that's immune system related. If you can desensitize immune system for the food allergy they have, why can't we desensitize the mind where they have overactive mind? Now, uh, I, I know you love that subject and I want to learn more from you, so I'm going to

Amanda Whitehouse, PhD 8:46

Okay.

Atul Shah, MD 8:46

that on you. So

Amanda Whitehouse, PhD 8:49

Sure

Atul Shah, MD 8:50

if you don't mind, please. So, so tell me how do you define anxiety?

Amanda Whitehouse, PhD 8:55

They're so parallel, right? It is a physiological process, right? It's not, as you described, it's not a conscious, intentional process. I'm a very nervous system-based practitioner. Um, so it's, it's not just in your brain or in your head. It's throughout your whole body and your entire nervous system. And then of course, you could probably speak better than I could about this, but it's not just that we could desensitize both of them, but they feed each other. It's cyclical. So the anxiety and the nervous system being on alert can lower the threshold and exacerbate the physical problems and vice versa. Obviously, your anxiety is worse if your medical situation is not well and your nervous system responds. So it only makes sense to do things in parallel. And that's what I tried to get across at the FAST meeting when I spoke. What all of you physicians who are offering OIT are doing is already set up to do, you have the term psychological desensitization, we call it exposure with response prevention. So instead of exposing them to the allergen, we're exposing them gradually within the appropriate, manageable amounts and degrees to increase their threshold for that anxiety-provoking situation, which happens to be the allergen that you're already exposing them to. So I think it's a beautiful setup to do exactly what you're doing, and little by little, help the system learn, much like in OIT, to tolerate a little bit more. And then obviously, the safer that they're getting because of the treatment, the easier that is to do. They just go hand in hand so well. I would love for you to talk more, throwing it back to you, how do we get more providers to do that and to understand that it is doable and you have time and that it's possible to incorporate that alongside the treatment?

Atul Shah, MD 10:36

I think it, it's a very good question, and I think it all begins with awareness. The physicians first now they're learning how to make proper diagnose of food allergy because, the allergy fellowship programs do not have formal training on food allergy in most institutions. Many fellows who come out have not been trained how to do sublingual immunotherapy or OIT. That's the sad part, but it's changing. It's happening. It's getting better. But the young physicians who want to learn, they come to meetings like FAST, and then they approach us, and then we continue to educate them, teach them. And as they learn, they get comfortable doing immunological desensitization. when they attend the sessions where you, you presented at FAST, or to this kind of podcast, or they read the books that you have, or they interact with other colleagues, then they realize that, yes, they're missing out on helping their patients with psychological desensitization. So I think the first step is awareness among allergists' community. Once that happens, resources are out there. I mean, you have the resources, and I'm sure if they're part of institution, they may have local resources. If not, families can identify the resources online and otherwise. I think, I think the really first step is the clinicians need to have open mind that, "Okay, I have not had any formal training in this space. Can I actually listen to somebody who's good in this area?" and I think you have already started that mission.

Amanda Whitehouse, PhD 12:04

I think we will probably all find, I'm sure you can attest to this, I would think that your patients would be so much more successful medically when you're treating the whole person in this way.

Atul Shah, MD 12:15

Yes. We, we see that. So when we set up our very first treatment session, every room was made as a pleasant room. I still have M&M peanut cups. I still have like candy dispenser that's a shape of M&M peanut. Now, think of a child with peanut allergy. All their life they have been told that, "Don't touch it. Don't go near it. Don't put it in your mouth." where does it stay? It stays in their mind. Now, through the process, halfway through, now we said, "Oh yeah, it's okay. Now you can have peanut in your mouth." they'll take 20 minutes to take the peanut from the cup to put into it, into their mouth there is built-in stress and anxiety that's coming up at the surface. So what I realized early on, if I expose them to friendly face of peanut from day one, it will be easier. everything we plan in the office has a happy face of the peanut in the area where the peanut treatment is being done. So without their knowledge, they're subconsciously being exposed to happy faces of peanut.

Amanda Whitehouse, PhD 13:17

That's a perfect way to demonstrate that you're desensitizing them to it psychologically. How do they feel about it? What do they associate to it? What emotions come up when they see a peanut? I love that so much. Oh my gosh, that's beautiful.

Atul Shah, MD 13:32

But we also bring up conversation. We allow them to talk about how they feel. It's equally important. We may not be as good as doing a therapy as you can do, but I think we have a responsibility to open up those conversation, identify who needs professional help, and then refer them to professionals who can help. We also found that journaling is a very good tool. So, so my food allergy journal that we actually prepared for our patients that families request us to put it on Amazon, is nothing but a journal guided to help them go through the journey of OIT. and the whole purpose is when they take time to write how they feel, it is nothing but a form of therapy. They're doing it themselves before they get to you or before they ask for professional help, and that I have been doing since 2015.

Amanda Whitehouse, PhD 14:22

That's amazing. My workbook is journaling too, because sometimes it's not necessarily about evaluating or making the feelings go away, it's just bringing them to awareness, right? So much of this is unconscious and, and not intentional. So, you've been doing that part of it since 2015. How long have you actually been doing OIT?

Atul Shah, MD 14:40

My very first OIT, which was hush-hush, we didn't want world to know what we were doing, was 2013, 2014. Once we saw some successful results, 2015 is we made it public

Amanda Whitehouse, PhD 14:50

My son was diagnosed in 2012, so 2015 must have been around the time that I saw the work that you were doing and trying to find somewhere to get him for treatment. And so that was my guess, but I figured there was some more backstory because it was a little bit controversial at first. Can you tell people why?

Atul Shah, MD 15:07

Any change that happens in society, initially there's resistance, then there is interest, then people want to do it, and then it becomes norm. Like, look through even we when we got our first, uh, cell phone. I think even when the cell phone came out, there was initially, you know, people are questioning, "What's this? Why should we have it?" This, you know. Now we can't leave home without cell phone. So I think medicine also goes through that. So whenever there's a new treatment, science-based, but if the allergy community is thinking in one direction, there's going to be resistance. we are part of the resistance in the beginning. Then there was interest, and I think we are at a point now, it's a tipping point, where everybody wants to learn about OIT and more and more family want to get into doing some form of treatment. And I think it's a wonderful thing because more families will benefit.

Amanda Whitehouse, PhD 16:00

You talk about there being a tipping point, what comes to mind for me are a lot of the fears and the myths and misconceptions about OIT that I think are still hanging on there, but hopefully we're clearing up. Why don't you share how you see those being cleared up over time in terms of people really understanding what it is and how effective it can be?

Atul Shah, MD 16:21

Yeah. So it's two aspects. One is the allergists themselves. So the allergists who are in general allergy practice, they need to embrace food treatment, and all begins with proper diagnosis. Positive skin test does not mean patient has allergy. Skin test simply means they have been sensitized. Positive IgE blood test does not mean patient has allergy. Simply means they have been sensitized. So I think there's a need for allergists to accept that we need proper diagnosis before we recommend any treatment, that's something our focus has been. Once they have the proper diagnosis, there are treatment options. It could be sublingual, it could be oral immunotherapy, it could be biologic, or you can combine one or the other, or you can transition one to the other. I think they can provide better care, and it starts with proper diagnosis. On the other side, families who have been told by their experts, whom they trust that these are their experts, saying that nothing can be done and nothing should be done, it holds them back even if options are becoming available because they're trusting their local physician, local allergist, they're holding back. And that's where the awareness helps. Them listening to this kind of podcast, listening to other social media things, I think will help them understand. We need to publish data. So for example, Dr. Jones and I published data where common belief among allergists is the OIT has more risk of anaphylaxis. Now, most allergy practices do oral challenges, so we had to prove and show them through data the oral challenges have actually much higher risk of reaction than the OIT itself throughout the journey. Now, if general allergist who is not doing food treatment because he's afraid of anaphylaxis in the office, but if they are doing oral challenges, here's a message for them, if you're able to do challenges and able to take the risk, and if the risk of anaphylaxis is less through treatment process, why not to do the treatment? The second part is now we know that avoidance is actually more harmful to the family. Child who has a positive blood test and had a minor reaction, and if there's a window to do some form of treatment, longer you wait, that IgE is going to continue to go up. Now, if they decide to do the treatment five, 10 years later, now we have more work to do, and you also have longer duration to bring that IgE down. our message is very clear: catch them young, start the treatment as soon as you can, and sometimes you... they may not need a full treatment because partial treatment might be very, very effective them, very effective at that stage. So we start now treatment in infants.

Amanda Whitehouse, PhD 19:08

Why don't you talk about that a little bit? Because obviously we're learning more about early introduction and hoping to prevent or at least reduce the frequency of food allergies. And then obviously some children, a smaller percentage, will still develop the allergy. So talk about the importance of that early introduction and then what happens for that percentage who does still develop an allergy, if they can find a doctor like you at least.

Atul Shah, MD 19:30

Sure. So 2015, we had a milestone study that showed that early introduction of high allergenic food can reduce the possibility of developing food allergy. And it was very statistically significant for peanut allergy, and many studies now trying to prove that it applies to other allergens as well. So it's a generalization from the peanut study to other foods. Now, what happens is if you look at a larger picture, when a baby is born, they go through a process of we call natural tolerance. the baby is given the food, their immune system adapts to that food, and they do not become allergic. The infant who becomes allergic, their immune system develops IgE, which also comes from the same B cells, which are one form of white cells. Instead of making IgG, they make IgE. you make IgG, you have developed natural tolerance. If you develop IgE, you have become allergic. If you do early introduction, then you have more chance to develop IgG rather than developing IgE. Longer you wait, you have a higher chance to develop IgE, and that's why the chance of becoming allergic is higher. Now, this was almost 11 years ago, and still many infants do not get peanut or eggs on time. you want them to be at least introduced close to six months of age. It can be as early as four to six months of age if they're high risk. Now, what is happening is if we are delaying that, you're seeing more and more children becoming allergic. If you miss that, now if child has already become allergic, the IgE is still on the low side, and longer you wait, those B cells will continue to make higher amount of IgE. So something that's in the range of, let's say, eight or nine, next year might become 12 or 15. The year after will become 25, and now the higher the number, the longer it's going to take for it to come down after any form of treatment. So our message is very clear. If you're not allergic, let's do early introduction. Make sure you don't become allergic. If you already become allergic, do not wait. Do not allow numbers to come down naturally. Yes, milk, eggs, you have a significantly higher chance for things to get better, can still introduce baked milk or baked egg early in life so that you do not need OIT down the road. Children who have become allergic to milk or eggs, but they're on the lower IgE side, you can introduce baked milk or baked egg so that they don't have to go through OIT two, three, four years later.

Amanda Whitehouse, PhD 22:07

That's really painting the picture of what we talked about before, how harmful it is when either their pediatricians who may not be informed or their allergists who don't offer the treatment are discouraging people, particularly with this window of time that's so sensitive to catch them early and have the best possible response to treatment, unfortunately. But flip side of that, I think a lot of people think you can't treat a food allergy if you're an older child or an adult, and that's not necessarily true either, right? So could you talk about treating older patients?

Atul Shah, MD 22:36

That's correct. Our immune system is the same, if we have figured it out how to do it in a younger age group, you can do it on older age group. may require a little bit more monitoring in certain areas, different way to approach things. but we are very, very proud that we have larger population of adults doing OIT in our practice. We didn't plan that way. It happened. We have office in Manhattan, and when we opened, we thought mainly the children with food allergy will come to us. Young professionals who have completed college, they're working in the city, they have a nice job, because of food allergy, they don't have social life. They can't go to bar. They don't have a date. If they do have a date, they're so restricted on what they can eat, what they cannot eat. the quality of life became an issue and is, is an issue for many young adults. So we started seeing, uh, older and older adults, and the oldest person we have completed treatment is fifty-five, eating freely. So we believe that if you take the science, personalize it to the patient's need, you can do any form of immunotherapy at any age. We just don't say OIT. This is where we, you know, founded a program called FATE Program. It stands for Food Allergy Tolerance Enhancement Program. So if tolerance has not happened naturally, we'll help you get to tolerance, and that tolerance can be different for different person. It could be safety or it could be freedom, and that's the goal for... And, and that includes the OIT, that includes the sublingual immunotherapy if needed. It includes the biologic products.

Amanda Whitehouse, PhD 24:14

Why don't you tell us more about the FAIT program and what it looks like for someone showing up to your office for the first time interested in treatment?

Atul Shah, MD 24:21

Wh-when you look at a larger picture, all these fragmented treatments are available and it is confusing to families. So I needed to give a framework where it is easy for them to understand. So we label as FATE. It, it's their fate that they're seeing me, it's my fate that I get to help them. So and it's Food Allergy Tolerance Enhancement, so someone who has not naturally become tolerant, I can increase their tolerance. It really starts with basic history, so we have put into five steps. Step one is actually the real deep clinical history, whether they have had a reaction or they just had a positive skin test or positive blood test. Sometime baby has an eczema, goes to pediatrician. They have had a panel of testing, everything is positive, but baby never had that food, never had a reaction, and they're labeled as allergic to ten items. Now, those children do not need OIT. We really need to take a detailed history and go through what's causing eczema, fix the eczema, do repeat testing, and if things they are not eating, if we are able to introduce, we'll be able to do that. So that's the detailed history. Someone has had a reaction and we want to go into detail of what kind of reaction. Is it a contact reaction? Is it pollen-related oral allergy syndrome? Is it a true allergy, whether it's non-IgE allergy? Is it FPIES? So history is very, very important to know what is going on. Second step is proper diagnosis. So skin test is one way to diagnose, but we also know that skin test cannot be used for treatment decisions. So we use IgE we do component testing, and now we have access to something called basophil activation test. if needed, we'll talk about it, but that something is a game changer for us in how we make diagnosis and also how we manage certain things. Step three would be to do oral challenges. So there are still situation in which you need to confirm diagnosis true or you can feed them, so they don't need a treatment. That's where we do gold standard oral challenge. Once we confirm they have a true allergy, then they go through the process of deciding what's the right treatment for them. it could be sublingual immunotherapy, it could be oral immunotherapy or with or without biologics, or it can be transitioning from one to the other. based on their goal, we take them to the last step, which is either they stop it when they're bite proof and safe, we take them all the way to freedom. we also do for single food or multi food. Patients who have multiple food allergy, they don't have to go through one cycle at a time. Every patient's need is different. Their goals are different. As simple as, we saw a family where child has allergy to milk, eggs, and sesame, and we offered them to do multiple food together. But for them, every time they're in Israel in summer, child needs Epi because of sesame cross-contamination. It's very hard to avoid sesame in Israel. Now, family said, "Milk, eggs, we are able to avoid. We don't want to do the treatment. Take us to freedom for sesame, so next summer we can be in Israel and not worry about needing Epi." even if I can help them with multi-food allergy, they're choosing to do only sesame, and that's okay. We'll customize what that child needs. So again, going back to your original question, what you're suggesting through your book is yes, every treatment, whether it's immunological or psychological, should be personalized, that's our approach. Yes, child has a food allergy. Their success is their success, and their goal of success is very different.

Amanda Whitehouse, PhD 27:53

And as you mentioned, a lot of patients are overwhelmed with all of these options and decisions and understanding the differences between them. How do you guide them through that? Because it is tough. It's their decision, but talk to us about how you help them understand all of the options, and then take them through the process of landing on what they think will be best for them at that point in time.

Atul Shah, MD 28:14

So the beautiful thing is child under four does not get a choice. Mom or dad or both will make the decision. So under four, we tell parents, what's possible. The younger you start, better the outcome, and we still offer them to do multi-food. And what they need to understand is the commitment. What we try to convey is not a one visit and you're done. a commitment for extended period of time. Again, common misconception here is patients have been told when you do OIT, it's a lifetime treatment, which is also not true. The amount of food you need in the beginning and the frequency you need is higher, but as your IgE comes down and your basophil activation shows your cells are non-reactive, you can actually reduce the dose, reduce the frequency, and if you start eating freely, you may not even need the dose at all because your free eating gives you the dose. So we discuss all this upfront, and then we really allow them to have time to think through what commitment they can make. It's okay to take extra two weeks to make a decision, but we want them to stick to the decision once they have made. When it comes to younger children or teenagers, we again have the discussion, mainly teenagers, the sports they're playing, AP classes they're taking, the amount of time they'll need to come to the office, amount of commitment they'll have at home, if they have exercise restriction, what precautions they'll need. All that has to be discussed upfront, and we need their help to help them. So usually we have discussion with teenagers in their language. Most of them are playing sports, so we tell them, "Okay, if you want to be an athlete playing baseball, you'll have a coach. Your parents will take you to practice. Your coach will tell you where your potential is, where you need to put the effort, but effort is in your control. If you don't practice, coach can't help and your parents cannot help." And once we get them that message, they understand that it's their commitment. And some said, "We are not ready," and that's okay. We can wait. Some said, "I'm ready." And then, as you said in the beginning, the plan can change. They may begin with a goal of bite proof, but everything's going well and they see the freedom and they want to go to freedom, we'll take them there. sublingual immunotherapy could be initial starting point just to see... we use that sometime to check their compliance if they're compliant with sublingual immunotherapy, they're more likely to be compliant with OIT. they cannot keep up with sublingual immunotherapy, they're not candidates for OIT. So those are the early discussion that help us guide, and ultimately it is their decision. You can take the horse to water, you can't make the horse drink water. And I'm sure as a therapist you see that as well. You tell the patients, "Do this, do this." When they're having anxiety, you can give them a technique, but if they don't use when they need it, it's not going to work.

Amanda Whitehouse, PhD 31:08

Right. I've worked with many patients where the child was the patient, and they were not on board, whether it was anxiety or other reasons like you described. And things come to a head when the parents find two weeks' worth of peanut M&M doses in the garbage hidden, and the kids just are not cooperating. And pushing them to do it when they're not on board, I would think you'd see that too, backfires in a lot of ways.

Atul Shah, MD 31:32

Yes, agreed. At that time, everybody should be on the same page. And, and if parents are separated even they need to be on the same page. And, and that also is equally important. When we do the initial consultation and the consent for OIT and if parents are separated, we want to make sure both are in the room at the same time in front of the child, and they both agree on the plan. 'Cause otherwise, three days they're here, remaining two, three days they go somewhere else or next parents, and then they're not continuing the treatment. But I think it again goes back to communication, where if you can lay out what is expected but what's possible and we allow them to choose, most people with rational mind can see what they're capable of doing.

Amanda Whitehouse, PhD 32:19

You touched on it a little bit earlier, but the success that your patients are seeing and how life changes for them when they reach whatever their goals were

Atul Shah, MD 32:26

It is so life-changing that majority of them cry. We have a saying in my office that Dr. Shah makes men cry.

Amanda Whitehouse, PhD 32:35

I get it. I understand why

Atul Shah, MD 32:37

Yeah, I have seen numerous dads crying in my office on the day of graduation. Just last week, we had a 23-year-old who completed his milk OIT. As part of graduation, we allow them to bring foods made out of milk and try in the office. He had a regular slice of pizza, first time in his life at 23 years of age, and dad could not stop crying. He, he, he, he embraced him to the point he won't let him go. And, and when you're witness to that, you know that you're making a difference. And this is what drives us, me and my team, we look forward to seeing those emotions, and then it's so wonderful to be part of that journey

Amanda Whitehouse, PhD 33:18

That's beautiful.

Atul Shah, MD 33:19

We tell families to complete the circle, so we actually ask them to bring the food that gave them the first reaction. Like recently, we had, again, another adult completing egg OIT, and said when she was six month old, when they tried egg for the first time is when she had the reaction. So I said, "In what form?" And she said, "Well, scrambled egg." I said, "Sure, bring it." And we allowed mom to feed an adult daughter scrambled egg. So psychologically, she knows that she completed her cycle. And, and once you do that mom is going to cry for next half hour. and, but it is so relieving for her and releasing for her as well.

Amanda Whitehouse, PhD 33:59

I don't know if you would use these words to describe that or if you do with your patients, but that's trauma healing. For us parents who witnessed our children that sick, those are traumatic experiences. And so to relive that and heal that by walking through it again, like you said, completing the cycle, that's beautiful trauma work. I love that you do that. There's one really important topic, that I know is a big interest and specialization of yours that a lot of people don't know, we haven't talked about on my show yet very much, is the basophil activation test. So can you talk about BAT testing, what it is, how it's different, and how you use it in your practice so people understand it?

Atul Shah, MD 34:33

Sure. So BAT, or it's called basophil activation test. So before I describe the test, I would go back to how human body functions and how allergy responses happen. So if you look at it in our blood, we have three components. We have cells, we have fluid, and we have certain proteins Now, among the cells, we have red cells, white cells, and platelets. We all know that the red cell gives the color to the blood. White cells have five different types, and platelets is what helps us clot the blood. When someone takes aspirin and they say they're on a blood thinner, it actually works through the platelets. Now, when you look at those white cells, one of the white cell is called basophils. are similar to what we call mast cells. So when somebody having an allergic reaction, mast cells in the tissue is what is releasing histamine. In the blood, the cousin of mast cell is basophil. Now, if we have to check how allergen triggers the allergic response, there's no way to take out the mast cell from the tissue, but blood draw is so easy. So what you do is you draw the blood, you separate the mast cells, and you put them with the allergen. So let's say we have a patient who has a peanut blood test positive but has a positive skin test but never had peanut. what would you do? Would you do OIT? Would you do SLIT, or would you actually get the proper diagnosis? proper diagnosis at this point requires oral challenge. Now, if someone has a positive blood test beyond certain number and you do oral challenge, you take the risk of them needing epinephrine. most parents would be uncomfortable giving peanuts when you have very high skin test positive or blood work, including allergist. what's the way out? So this is where basophil activation comes in. It is a challenge done in the test tube. You draw the blood, you separate the allergy cells. You put them with peanut at six different concentrations, and you allow the cells to react to peanut and see at what level the cells start reacting. Now, if cells react to every concentration, peanut allergy is real, and you should plan for a treatment. If cells don't react to any concentration, then child likely has a false positive skin test and blood work, and they should go for full challenge, and they should go to free eating as early as four hours of the challenge. they have partial response, meaning cells don't react to first three concentration but they react to the last concentration, they are partially non-responsive to peanut. Those are the patients I would start them on a microdose under observation and hold them on their dose for three month and six month and repeat the basophil activation. And if cells stop reacting at a higher amount, they're ready for a challenge. are the families do not need OIT. So, all this information we cannot get through skin test or IgE testing or the component testing. And that's why I have become kind of pioneer in taking basophil to clinical practice. And we started with peanut, but now we can offer to almost twenty-two different foods: milk, eggs, wheat, soy, sesame that's nutshell basophil activation test. You activate the basophil with the food, get the response, and it is as good as doing oral challenge but in the test tube.

Amanda Whitehouse, PhD 37:51

It's bridging the gap between the imperfections and the testing that we have already. I know the joke at FAST was you're Batman because you're so big on, you know, trying to pioneer the use of this. I know you're trying to teach your colleagues who are active at FAST, but why aren't more people embracing this?

Atul Shah, MD 38:06

Uh, it is very resource intensive test, so you need the cells to be alive to do the test. So from the time you draw the sample till the sample is processed, you have only seventy-two hours. So logistically, we have to make sure that anywhere the blood is drawn, it reaches our lab within that time. So we have other allergists sending us samples, but we add in through overnight FedEx, so we get it within twenty-four hour, and it is processed in the next twenty-four hours, so we get the proper results. Second is, most regular blood tests are covered by insurance. This is so labor intensive, and it's a new test, so some insurance companies will cover. Many insurance companies don't cover, so cost becomes prohibitive. But the way I look at is if you can avoid a child needing OIT just by doing basophil activation and doing a challenge, it is still worth the cost of doing it. But that's how what my colleagues need to understand that, yes, basophil activation is not needed for everyone. When someone had a reaction three months ago, tests are positive, and you know it's true allergy. You don't need basophil activation. But situation in which the diagnosis is not clear, basophil activation is very, very helpful.

Amanda Whitehouse, PhD 39:19

Could you share a little bit about the statistics on how accurate or how much more accurately it's able to identify? Or is that too hard to sum up?

Atul Shah, MD 39:27

So there has been a published article from someone named Alexandra Santos. She's in King's College London. She published the data, and when you compare to skin test, blood test, even IGE test, IG component test, and there's also a test called Mast Cell Activation Test that's being developed. you compare that, basophil activation has the highest sensitivity and highest specificity, more than ninety-five percent for individual foods. So among available all the test BAT has been the best sensitivity and specificity. What it means, then the chance of false positive is very minimal and chance of false negative is minimal. And that's what has helped me provide better care to my patients.

Amanda Whitehouse, PhD 40:17

What can people do if that's not something that their doctor is offering? How would they access that if it's not offered to them?

Atul Shah, MD 40:23

Yeah, so, so they can go through our website, but also they can ask their allergist, because you still need help from their allergist to manage the patient. what is happening is patients are telling their physicians that, "I want this test," or, "Can you consider this test?" Then the allergist will reach out to us, then we discuss the clinical case with them and see if there's a value of basophil activation, then we help set up their practice with our lab, and then we get the sample, we do the testing, and we provide them the results along with interpretation on what the value of the test is. That's going to grow for sure. Right now we're at a point, I'm in private practice. I am New York Food Allergy Wellness Center, but I have academic institution reaching out to us to help their patients to get the basophil activation done.

Amanda Whitehouse, PhD 41:11

You've been on the cusp of these new treatments and now this new testing, so you are the perfect person to wrap up the season by asking what is next? What's the future of food allergy treatment look like, and where do you see things going?

Atul Shah, MD 41:24

If food allergy family is listening, I'm telling them that the treatment is already here. Embrace it. And as far as science is concerned, I think the treatment will become patient-specific by using the technology as well as science and also AI. When you combine AI data, the current available treatment options and the basal activation, I think you can have a very specific patient-targeted treatment. It will be very more like shorter and faster and also they will reach freedom faster. So future is here. I won't even say future is five years down the road. Just in simple terms, when I was in my training to become an allergist in nineteen ninety-seven, I was told there is nothing you can do for a food allergy patient. You have to avoid, you have to give them epinephrine auto-injector, and you pray. Those are the only three things you can do. part of me in nineteen ninety-seven said, "I think in my lifetime I'll be able to help food allergy families," and it's a reality now.

Amanda Whitehouse, PhD 42:28

Unfortunately there are still people who are being told exactly what you just said in 2026. And so thank you for all of the work you've done to help people understand and to develop the treatments and to do it so well, to do it so, I would call it holistically in terms of the way that you approach your patients as whole people and families, and for helping me to spread the word to them so that they know there's more out there.

Atul Shah, MD 42:49

Dr. Whitehouse thank you for having me, and I admire you for your mission. It's not easy to have podcast. You invest your time to get the guest lined up, ask questions, put it together, and let the world understand what you're doing. So I, I thank you for your commitment. I thank you for your passion. And I think number of lives you're changing through your work, it's amazing.

Amanda Whitehouse, PhD 43:12

It was an honor to have you. Thank you so much for being here, Dr. Shah, and I look forward to more conversations in the future.

Speaker 2 43:17

Thank you again, Dr. Shah, for being here and for helping me to close out what has been such an important season of conversations about food allergy treatment and what has really been a life-changing experience for me because it led to the creation of my book. I really appreciate the way that all my guests this season have helped us think flexibly and individually about managing our food allergies in a way that works for us in our actual lives. I hope that no matter what your decisions are, that what you'll be taking away from this season is the recognition that every patient has different goals, circumstances, and needs, all of which are important, and the reminder that your psychological experience of treatment is just as important as the medical factors. Here are three action steps to follow up on today's episode. Number one You can follow him on YouTube at NYFoodAllergyWellness, on Facebook at NYFoodAllergy, on Instagram at NewYorkFoodAllergy, and on TikTok at NYFoodAllergy. Number two, you can also check out Dr. Shah's guided journal that he created for his patients on Amazon. There are also two children's books that he created about allergies and asthma. One is called Allergies and Awesome You: Believe You Can Get There Too, and the other one is Asthma and Awesome You: Believe You Can Get There Too. And if you go to Dr. Shah's website, nyfoodallergy.com, you'll find a lot of resources, including on the main menu a food allergy game that has tons of activities to teach kids about food allergies. That is free, has a handful of different activities to teach kids things like finding safety, reading labels, getting ready for restaurants, and identifying their allergens. Number three, if you've been following this season because you're thinking about food allergy treatment, navigating a decision, or already in the middle of or in maintenance for one, check out my book, From Fear to Freedom. It's specifically focused on the emotional and psychological side of food allergy immunotherapy and treatment decisions. The book takes everything that I've shared in this season of the podcast and expands upon it, adding in the psychological, social, and emotional aspects of each of the topics that I've covered with exercises and activities to help parents, patients, and children through these experiences with support and more insight. You can find my book on Amazon as well. This season has been incredibly meaningful to me, and I'm excited and proud about where it led. To every guest who shared their expertise, their lived experience, their research, their stories, and their honesty, thank you. Thank you so much to all the clinicians out there and researchers who are continuing to move allergy treatment forward. And thank you for supporting my work and listening to the podcast. And if you've enjoyed this season, I would really appreciate it if you would take a minute to leave the podcast a rating or a review wherever you listen. It helps other food allergy families find our conversations, and it means a lot to me. Thank you for being here for this season of Don't Feed the Fear. And you can look forward to beginning season nine this fall, beginning next week.

Amanda Whitehouse, PhD 46:17

The content of this podcast is for informational and educational purposes only, and is not a substitute for professional medical or mental health advice, diagnosis, or treatment. If you have any questions about your own medical experience or mental health needs, please consult a professional. I'm Dr. Amanda Whitehouse. Thanks for joining me. And until we chat again, remember don't feed the fear.