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Evolving Take on The Hygiene Hypothesis: The Epithelial Barrier Hypothesis

Kara Wada, MD writes about the hygiene hypothesis, which states that our modern lifestyle has led to an increase in immune system disorders, such as allergies and asthma.

June 21, 2023

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

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

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

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

 

For our skin: 

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

 

 

For our respiratory tract:

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

 

“Skip fragrance, dryer sheets, and fabric softeners. They are common allergens and often contain endocrine-disrupting chemicals.”

 

 

For our gut:

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

 

At the core, though, we need to remember to just do the best we can with the knowledge & bandwidth we have.

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

All opinions published on SomeDocs-Mag are the author’s and do not reflect the official position of SoMeDocs, its staff, editors. SoMeDocs is a magazine built with the safety of free expression and diverse perspectives in mind. For more information, or to submit your own opinion, please see our submission guidelines or email opmed@doximity.com. Do you have a compelling personal story you’d like to see published on SoMeDocs? Find out what we’re looking for here and submit your writing, or send us a pitch.

All opinions published on SomeDocs-Mag are the author’s and do not reflect the official position of SoMeDocs, its staff, editors. SoMeDocs is a magazine built with the safety of free expression and diverse perspectives in mind. Do you have a compelling personal story you’d like to see published on SoMeDocs? Submit your own article now here.

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