The Crunchy Allergist 0:03
Sick of the fatigue and fog? Fed up with the unpredictable flares? Hangry from the super restrictive diets?
The Crunchy Allergist 0:12
Hello and welcome to the Crunchy Allergists Podcast. A podcast empowering those who like me appreciate both a naturally minded and scientifically grounded approach to health and healing.
The Crunchy Allergist 0:24
Hi, I'm your host Dr. Kara Wada. Quadrupel board certified pediatric and adult allergy immunology and lifestyle medicine physician, Sjogren's patient, and life coach.
The Crunchy Allergist 0:35
My recipe for success combined the anti inflammatory lifestyle, trusting therapeutic relationships, modern medicine and mindset to harness our body's ability to heal.
The Crunchy Allergist 0:46
Now although I might be a physician, I'm not your physician and this podcast is for educational purposes only.
The Crunchy Allergist 0:54
Welcome, everyone. Today I'm excited to share with you a special episode of the crunchy allergist podcast. I recorded this episode during our first Annual Virtual Sjogren's Summit that took place April 1st and 2nd 2022. Around 1100 Sjogren's superheroes from over 18 countries and 38 states joined forces last week to kick off the Sjogren's Awareness Month.
The Crunchy Allergist 1:18
What is sjogrens exactly? Sjogren's is a systemic autoimmune disease that commonly causes dry eyes, dry mouth, fatigue, and pain. This condition affects up to one in 100 people 90% of whom are women, and many who are not aware of they even have it. I am a Sjogren's superhero, and one of the symptoms that is commonly shared amongst sogie and others with misbehaving immune systems are problems with digestion. So today we are going to dive in and answer many of your burning questions about food allergies, intolerances and sensitivities. Let's hop in.
The Crunchy Allergist 1:54
Good afternoon, everyone. My name is Kara Wada. I am the person spearheading this event. And I had a question asked earlier this week about food allergies versus intolerances versus sensitivities. And I had a little extra time over lunch here, and thought I would hop on and share what I only know about it. I talk about this in the office a lot.
The Crunchy Allergist 2:21
It is not uncommon to hear that people have difficulties when they eat particular foods. And I love to share kind of how I think about those circumstances. And so we can take in. So when we think about how this impacts Sjogrens Syndrome, we know that about 90% of patients with Sjogren's have some sort of gastrointestinal symptoms. Whether it is difficulty with trouble swallowing something I have, with some frequency with my dry mouth and maybe other contributing factors. It's not uncommon for me to have food go down the wrong pipe, or have a little more trouble kind of getting food down.
The Crunchy Allergist 3:09
Heartburn is another issue or reflux. Some people will feel heartburn, other people will not which is sometimes called silent reflux. And that can contribute to hoarseness and the voice sometimes or even nasal congestion or feeling like there's something stuck in your throat. And then certainly stomach or abdominal pain, discomfort, bloating, constipation, diarrhea symptoms suggestive of irritable bowel. And certainly when we think of Sjogren's and autoimmunity, there's always the potential for other autoimmune conditions. And there are several that can affect the GI tract.
The Crunchy Allergist 3:47
Most common those include celiac, which is about one in 100 patients. That is when the body essentially attacks the small bowel when there is gluten also present in the diet. And so that's one instance. And then another instance would be inflammatory bowel disease, which there are two varieties that we talk about most, Crohn's disease, and also all sort of colitis.
The Crunchy Allergist 4:17
I'm going to talk about a few other conditions that I see kind of in the office that have no like direct to known association with Sjogren's. But certainly if you have one thing, doesn't mean you can't have another. And just to kind of talk through how I think about bad symptoms that happen when we eat particular foods. So when we think about digestion, and our GI tract in general, it is one of the main ways that we are exposed to our external environment. The other ways that we're exposed to external environment are our respiratory tract or the way that we get oxygen. So breathing in so you'll hear from me on Saturday kind of talking about that interface. And then another interface that is really important is our skin. So in each area, in each of these areas of our body, we are seeing interaction between the external environment, our own cells, and including our immune system cells, and also microbiome. So the different bacteria, and viruses and fungi that live in and on us. And it really has only been in the last decade maybe, that we've really started to tune in to this really complex and elegant interplay between all of these different elements that microbiome was kind of not thought much about, and was really just kind of starting to come into the conversation as I was going through my medical training. So it's really exciting time to learn all about that. But digestion starts in the mouth with our saliva. You'll hear Dr. Julian talk a little bit about that as well. But it starts when we start chewing food, and then certainly makes its way down our esophagus, into our stomach, there. It should hopefully be an acidic environment. But sometimes we end up using medications that decrease the acid content of our stomach, especially for dealing with heartburn.
The Crunchy Allergist 6:25
And then after it has been digested in the stomach moved to the small intestine, some additional enzymes and other substances are added to help continue that digestion process. That's also when we start to see more of the microbiome coming into play helping break down some of the different sugars, carbohydrates and other proteins and fats that we are digesting. And then as it is making its way through the small intestine, a big aspect of that is absorption of nutrients. And then it gets to the large intestine where things collect and things solidify a little bit more. So that is where more water is absorbed. And you can imagine if what becomes our poop is taking longer to move through this large intestine, then that can lead to more constipation, or if things are moving through more quickly, that could lead to looser stools or diarrhea. All right, so that's kind of the basic overview of how food goes in and comes out. So what are some of the things that patients will talk to me about when they come into the office, maybe having symptoms related to particular foods, how I kind of how my brain is trained to think about things, is thinking about what the symptoms are, and then also thinking about what could be causing those symptoms to occur. And trying to think about that in a systematic framework so that we're not missing anything.
The Crunchy Allergist 8:02
Okay, so the one aspect that we see and unfortunately had dealt with in our family is what we call true food allergy. So in that situation, the immune system has recognized a particular food, typically protein, as the enemy, and it creates a protein called I G, E protein, or IGE antibody, so allergic antibody. And what happens is, when that food protein interacts with that allergy protein, it triggers our allergy cells, those allergy cells, then release substances that make us potentially throw up, have itchy hives, trouble breathing, similar to like asthma symptoms, and or can pass out or potentially be fatal reactions. There are nine foods that we think of that make up majority of these typical are these allergic reactions. But certainly there are foods outside of that list of nine that patients will have allergy to, and we've seen a pretty significant increase in the prevalence of food allergy over the last two decades. And I won't dig into that as much as I could, because I will otherwise be here for an hour and a half talking about this. But there are lots of thoughts on why that's happening. And it's it's not one thing that's changed, it's in all likelihood, a combination of things that have really resulted in that. But those foods we think about that are most common with true food allergy or milk, eggs, which is what my daughter Josie was allergic to wheat, peanuts, the tree nuts, so things like almonds, cashews, walnuts, so on and so forth. fish, shellfish, soy. And then sesame is the newest one added to the list. Again, other foods will come into play, I definitely have seen more circumstance or more issues with avocado in recent memory that probably in part has to deal with, we're eating more avocado than we were probably 1015 years ago. So that is true food allergy. And that is when allergy testing is helpful to confirm a suspicion for an allergy.
The Crunchy Allergist 10:37
So the big problem is if someone especially has like sinus allergies or other environmental allergies, it's not uncommon to see a person have allergy protein directed towards a particular food, either on those scratch tests or blood tests. But true food allergy is that the clinical situation so what happens when you eat the food, in addition to then that positive test, it has to be those two things. If you only have the positive test, we call that sensitization, it means your immune system has made a response. But it's not causing that actually you to have those reactions clinically like you could eat for instance. So you had, we'll pick an example, maybe you have a small amount of egg allergy protein, either a small skin test result where you get a little hive bump or a little a small amount on food allergy blood testing. But if you're eating eggs fine, like you can eat a muffin with eggs or you can eat scrambled eggs without a problem, then you're not allergic. It's, it's those two things together that make allergy. What becomes hard, especially in little kids is that sometimes allergy testing will be done before a kiddo has actually had a particular food. And so that's when it can be very nuanced to figure out okay, what would maybe be the safest way to see if they tolerate that food and when might it be safest to to give them that food and see how they do. We have some levels for a few foods that kind of give us some ability to try to better predict if that will be tolerated or not. We were very fortunate with my daughter Josie that her levels were never terribly high. She had an episode when she was about nine months old. She had some scrambled eggs. She ended up with some hives rashes on her hands and her mouth. And then she ended up throwing up so that would have been anaphylaxis. We did not have epinephrine at home at the time. Ideally that would have been the ideal treatment for her. We were able to give her some anti histamine and she ended up doing okay, we watched her at home but in the purchase history situation she would have gotten epinephrine and then been monitored. Because that is the best treatment for a true allergic reaction. And knock on wood she has outgrown her egg allergy, we were able to give her a supervised food challenge in her allergist office Oh almost a year ago. So she has been able to eat eggs. Since then. Not doesn't love them, but she will eat them. And we're trying to keep that in her diet so that she can have a a well balanced diet and try not to have any potential of that allergy coming back. Alright, so that's true allergy. Celiac, as I mentioned is another immune system response and it is a response of the immune system. In the context of seeing gluten, which is found it's a protein that is found primarily with wheat, but also several other grains like barley. And essentially the body makes white blood cells or immune system cells that then attack the small bowel, which then makes it really challenging for the small bowel to absorb nutrients. And so in about one in 100 people we will see or find signs or symptoms of celiac, celiac, kind of the the main way that that's diagnosed or the gold standard, the best way to diagnose that is through a scope where they look at your small bowel and they get a little piece of the tissue and look at that under the microscope. That's the best way to test for it. But there are some ways to screen for it through bloodwork and any of those tests are going to be most accurate. If you have that testing done while you are still eating gluten. If you've been gluten free for A period of time, more than two weeks or so, you can see that those tests can become negative over time. And that's actually a good thing overall, in that we want to see the body healing as you take gluten out of the diet.
The Crunchy Allergist 15:16
But that can be really challenging if you don't have the testing ahead of time, because some people may not have celiac, but they may not. They may have more of an intolerance to gluten or wheat, which I'll talk about in a little bit. And it's really helpful to know that and be able to distinguish the difference. So I really encourage people if you're going to go gluten free, or do a trial of a gluten free diet, to try to get testing at least the blood testing ahead of time so that you kind of know going in if this is going to be maybe celiac or an intolerance type situation.
The Crunchy Allergist 15:58
Okay, so those are the kind of main immune system things we think about. There are some other immune system related conditions that we are still trying to work through exactly what is going wrong. But these are conditions that I help diagnose. In my clinic, sometimes with the help of gastroenterologist or our stomach or GI doctors, and sometimes on our own. One of those conditions is called eosinophilic esophagitis, EoE. This is another condition similar to food allergy and autoimmunity that we are seeing kind of go up in its prevalence over, you know, the last several decades. Essentially eosinophils, we will call allergy white blood cells, there are several types of white blood cells we call allergy, white blood cells, that would be one of them. We call them Eo's for short, because it's easier to say and spell. But those cells should not be found in our Food Tube or esophagus. In this case, they are there and what happens when they are there is that they can cause people to have food gets stuck, that essentially there's inflammation there. So food does not travel down this esophagus as well. This can be more problematic with foods that from a texture standpoint are harder to swallow like breads, like chicken breast that is cooked too long, and other meats can be a little more problematic sometimes with getting stuck and rice is another one that will come up pretty often as well. With eosinophilic esophagitis, what we believe is happening is that there is in many cases, foods that are implicated in this. But what's frustrating is those scratch tests that we talked about with the true food allergy, they are not very good at predicting which foods are going to be a trigger, what we think is happening is a different type of white blood cell that can make memory is likely involved. And we don't have a great way of identifying or screening for that at this point in time. So what happens with these patients many times is we have a conversation in the office, would you prefer to use medication would you prefer to use diet or a combination of the two is your first step in treatment. And then if it is dietary treatment, we talked about doing trial of particular elimination strategies. We know for EoE, the biggest culprit that we see is milk protein. So that would be a situation where we may try kind of taking milk out of the diet not only milk, but cheese, butter, yogurt, any sort of dairy protein. So that's EoE.
The Crunchy Allergist 18:52
There's another situation that again, that we are seeing with patients called FPIES. FPIES is a really long acronym, which you can Google. But essentially what happens for these patients primarily kiddos is that they will be exposed to particular foods. In this case, the implicated foods tend to be milk and soy and real little babies like that maybe are either breastfed or doing formula or combination of the two. Or as kids get a little older will sometimes see this with other interestingly grains or legumes like different types of peas, beans, and certain vegetables like potato comes up to like foods that you normally would not think of as a problem. My colleague her little one has a problem with oats. Another colleague, it's kind of ironic allergists with all these kids with different food allergy issues, but her daughter had issues with rice. But what happened Is that kiddo or person will ingest that food that is the trigger food, and within about like 90 minutes to two hours.
The Crunchy Allergist 20:09
So this is a little longer out from a true food allergy which is more immediate, these kids will start throwing up and throwing up and throwing up and it is profound. And it looks like they have a really terrible stomach bug. And with little babies, because they don't have as much reserve, they can look really sick really fast. And so many times what will happen is because there are no rashes or other symptoms, people will think that they have a bad infection, and they'll go to the ER, they'll get fluids, they may get worked up for something called sepsis. And it may take unfortunately, a couple episodes before someone realizes, hey, this is only happening after the kiddo eats their, you know, their cereal or their sweet potato, little baby food or something along those lines. In adults, this is thought to be less common, but I do have a few patients who have had this happen. One has had it with poultry, I believe it was chicken and in their case, and then I have we know that seafood is another food that will come up. And you can have reactions in this way as well. And that's something that is described more, more often in the adult population that has this has this FPIES reaction. Again, another really frustrating aspect to carrying and teasing out the triggers for this is we don't have good testing, in part to identify or confirm the food trigger. It's it's kind of we determined it through a real in depth conversation with the patient. Because we're still figuring out the exact mechanism or what immune cells are implicated in causing this robust response. That is just saying, get this food out of here. It is not, it is not welcome here. And so there is a lot of work going on, especially out of Mount Sinai in New York. It looking at what exactly is going on what parts of the immune system are implicated? And how can we have better testing modalities to help identify these triggers. And also know when people are outgrowing so this is thankfully a situation that for little ones, they almost overwhelmingly will outgrow this, this type of reaction, which is really, you know, always the best case scenario.
The Crunchy Allergist 22:42
Okay, let's dig into things that are more common in tolerances are huge. So this is going to be many times and these are symptoms I have dealt with and in all sorts of varieties which I will not dig super into because TMI but bloating, gas, diarrhea, constipation. That upset stomach also can include other symptoms like headaches, feeling really like blue after eating. Kind of those symptoms that aren't fitting into these other categories can fall into kind of what we consider kind of these intolerances or sensitivities. There are some elements, or types of in sensitivities, or sorry, in tolerances that come up pretty often. So it is one that you most of you probably have heard of, at one time or another is lactose intolerance. So being unable to digest the sugar that is found in milk. So what happens in the situation is the lactose needs a particular enzyme to break it down that we ourselves as humans don't make, but our gut bugs can make. And what happens is when we're we little babies, and we might be drinking mom's milk or milk based formula, we have enough of these gut bugs and the enzyme they produce to break down that lactose.
The Crunchy Allergist 24:13
What happens over time, though, is that those gut bugs stop or decrease the amount of this lactase. That's the enzyme that breaks down lactose that decreases over time. In vast majority of humans. There are some people who come from Northern European ancestry that will have and maintain that lactase enzyme for longer, but most of us will lose this over time and certain backgrounds may lose it sooner than others. So I joke that when I started dating my husband who is of Japanese background, he has been lactose intolerant. He said he thinks since he was probably in his late teens, early 20s. And so when we started cohabitating and buying the same milk, he was buying lactose free milk at the time. And I started drinking that and there's a bit of a like use it or lose it phenomenon. And so I noticed over time that I had less ability to digest lactose. And it may have been just my time of losing tolerance anyways. But what will happen many times for people is that ingesting a bigger amount of lactose will then result in bloating, gas, and in many cases, some urgency to need to go to the bathroom, losers tools, diarrhea, and then other people sometimes milk can actually stop things up. And this is kind of been more of my MO is that if I have too much milk or cheese or lactose kind of situations in my digestive system pumps the brakes and is not not very happy. So everyone's a little bit different in tolerances also on the whole tend to have a dose effect aspect to them. So more often people will be able to tolerate small amounts of a particular substance and have more difficulty or more symptoms when they're ingesting larger amounts. So in the case of lactose, someone may do perfectly fine with like a little Parmesan cheese on top of pasta or something along those lines. But having a big milkshake is like Game over. So that's of course the extreme. But that is kind of lactose intolerance.
The Crunchy Allergist 26:36
What we've realized is that there are other carbohydrates and sugars that have similar properties to lactose, but aren't lactose. And so there are some doctors and researchers out of Monash University down in Australia that have done a good portion of the work on FODMAPs are FODMAPs, tomato tomahto, which are these other fermentable types of sugars that some of us don't digest well. And so those fall into different categories. But if you've kind of explored or dealt with these symptoms you may have encountered or come across kind of something called the low FODMAP diet, which essentially, is a strategy to help identify which of these particular food groups may be more problematic. So lactose is one of these FODMAP foods or groups.
The Crunchy Allergist 27:32
Another that comes up includes gluten. So this is where that gluten sensitivity or intolerance may come into play as well. There also is fructose, which is fruit sugar. Also high fructose corn syrup, excuse me, grandma water can also come into play. So that can be with a lot of like processed foods and sweets, certainly. And then there are a few others that fall into this as well. What we realize, though, is that these particular carbohydrates, and these foods also contain a lot of really healthy fiber, that can be really beneficial for our microbiome, our gut bugs, and help promote production of anti inflammatory substances as well called short chain fatty acids. So we've kind of had the pendulum swing from one side to the other of like, Oh, if you have these intolerances, maybe you should pull them all out and eat this low FODMAP FODMAP diet. And really what we're realizing now is that no, maybe you use that as a tool to help identify better what foods are causing symptoms, but then come up with a plan working with a dietician, or someone else who's well versed in this to try to help slowly but surely, give those gut bugs a little bit of a workout, by slowly reintroducing some of these different fibers into the diet, so that you have a way of allowing your body to see them without making you feel absolutely miserable. And over time, helping essentially rehab your microbiome. And so that can be really helpful and there are some strategies for instance, with for instance, beans, there are some ways that you can cook beans or eat them, start with particular types of them, which are going to help you digest them a little better so that you're not so gassy, bloated, feeling achy, but also getting some of the benefits of eating those as well.
The Crunchy Allergist 29:52
Another situation that comes up with intolerances that I increasingly am seeing patients for Are other something for instance, histamine intolerance. So there are inner foods there are other substances and that have biologic properties to them. So histamine is one of them histamine is a substance that our allergy cells make. It is preformed inside those little allergy cells. And it is the chemical that causes us to itch to flush to have if it's released in our GI tract to have stuff want to come out either direction. It is helpful if you are trying to fight off a parasitic infection, which is what its original purpose was, but not so helpful when too much of it is released, day to day. Now, interestingly, though, particular foods have naturally occurring histamine and or histamine is increases in its amounts in like leftover foods. Some other foods that would have higher histamine counts are like foods that are fermented or like sauerkraut, and pickles and things along those lines. And what can happen, and canned tuna and in other things are also notorious for this as well. But this is again, like a dose effect. So what can happen as if you're eating a lot of foods that are high in histamine and you're already sensitive? For other reasons, maybe you're on some medications that decrease your ability to break down histamine. Or maybe you have some imbalances in your gut bugs, that then you can have too much of this histamine floating around and have symptoms related to that. So this is something we're still kind of learning a little more about and how to best manage, but certainly, we'll see. And there are similar and related intolerances that can come up.
The Crunchy Allergist 32:06
So Salicylates. Another thing so salicylates are we think of them more as substances we use as anti inflammatories. So things like aspirin is a solicit aid, but salicylic acid and related compounds are also naturally occurring in particular foods. And so some people can be more sensitive to those and that would be something that sometimes may trigger like asthma like symptoms. So it can be really helpful if you are dealing with these sorts of issues or problems to work with a health care provider who is well versed in them whether it's an allergist, immunologist, a diet registered dietitian, a GI specialist, there's an sometimes you may have to kind of ask around to see who in your area is going to be that person that really kind of has an interest and is trying to help people deal with these with these symptoms. One thing I kind of was alluding to, that will come up and this is something that that I'm seeing increasingly and I'm trying to develop more comfort in identifying it and treating for it with my GI colleagues is something called small intestinal bacterial overgrowth or SIBO.
The Crunchy Allergist 33:25
And so this is essentially that imbalance that we kind of have reached kind of a clinical situation where it meets like a diet diagnostic criteria, and that is treated sometimes with particular antibiotics to help decrease the bad bacteria and allow for those good bacteria to thrive. And we think that it's some of these either SIBO or dysbiosis, which is on its way towards SIBO that are implicated in one way, shape, or form. To maybe increase permeability or increased community communication and that gut lining between what's inside the bowel. So the food and the partially digested food, the immune system and the microbiome, and then the bloodstream on the other side. And so we think it's this increased communication between the two, which is also known kind of as leaky gut, that has some implication in the development or and or progression of autoimmune conditions. And that's something that is still very much under investigation and I am like always kind of watching the literature to see what's coming out.
The Crunchy Allergist 34:45
What I found really fascinating. There was an issue of one of our main allergy journals that came out. A few months ago, I was still pregnant with Oliver, and was talking about the implications of mom's diet. And then the potential for baby to later on develop or be diagnosed with allergies, asthma and other related conditions. And so, we you know, we're just kind of on the cusp of kind of getting more of this information to help us you know, better advice patients, but really kind of the big picture things are, is best as you are able to tolerate. Having a broad diverse diet is really important. We also know that getting diversity in foods can be really helpful especially in plant based foods. So fruits, vegetables, nuts, beans, seeds, herbs, spices. I think I caught all of them. Whole grains, that's the other big one, can be really helpful because that's going to help your gut bugs see all those different types of fibers and helps those thrive and pump out more of those anti inflammatory substances. We also have seen some data to support making sure that our diet is rich in omega three fatty acids. So these are we more commonly think of as fish oil but are also found in plant sources like flax and chia and I know Jennifer's gonna talk I'm sure more about that.
The Crunchy Allergist 36:19
And also making sure that we have enough vitamin D in our diet and or that we're getting that from our from the sunshine as well. Because there are implications in not having enough diet, vitamin D and omega threes that will see more misbehaving in our immune system. So that is the not so quick and dirty on things that can happen with foods. And if you have any questions, drop them below.
The Crunchy Allergist 36:57
I can't provide personalized advice but I can help try to point you in the right direction. A couple of resources I have found really helpful. There is a book called fiber fueled, um written by a GI doc will I think it's still his last name starts with the B and I am not sure how to pronounce it. But that is a really great reference. I will say though, I did attempt to do the meal plan towards the back of the book. He is a whole food plant based physician and really promotes that. We have not checked we're more flexitarian in our household. But my personal opinion the meal plan is a little too complicated. For my lifestyle. It was delicious. The food was very good. It just was. It was a lot. And I tried that was on maternity leave. So I had more time to cook and shop and all those things and had some help and it still was a little too much. But some really good take home points on the microbiome diversity, implications and all of that that was really helpful. So that is one really good resource.
The Crunchy Allergist 38:10
Another good resource is, I believe it's called Food Without Fear. I'll double check the title and if that if I'm off on that I'll post the title below. That one's written by someone who's very involved in the food allergy scene, but she talks a lot about food allergy and things that mimic food allergy. So that is another really great resource if you are trying to tease through all of this and having trouble kind of connecting with someone locally.
The Crunchy Allergist 38:43
So if you want to learn kind of more about foods implication of food in our sjogrens journey, Jennifer Serani is going to have her talk on Saturday. She has an excellent resource and then I will be up with sinuses on Saturday to everything's going to kick off tomorrow morning. And kind of the little surprise that I think will be really helpful so we have kind of the times laid out you don't have to tune in at the specific times everything's going to kind of load both on the Facebook site and then on the login site, crunchyallergists.com/login, around 7am. So you can watch those kind of at your leisure.
The Crunchy Allergist 39:32
If you are wanting to tune into the question and answer sessions. You will get an announcement through the VIP portal with the Zoom login information. I'm going to do my best to try to stream that in the Facebook group. But that is something I haven't been able to practice ahead.
The Crunchy Allergist 39:02
This is our first year we are working through all the tech stuff and trying our best to bring the most value and education that we can to this but understand this is you know our first time at this particular rodeo. And so we're working through some of the hiccups with all of that it's been a super fun learning experience. But it's a learning experience nonetheless. So with that in mind, you will also see a link for a little survey afterwards and we would love, love, love any feedback particularly constructive feedback. Because that's always you know, a little more helpful than just the complaining.
The Crunchy Allergist 40:33
Oh, I hope each of you has a wonderful day. I'm going to work on hydrating up and getting a few things done before I finished up in the office. And I hope you have an awesome day can't wait for tomorrow. So excited. We take care of tomorrow so excited. Take care
The Crunchy Allergist 40:56
If you are curious about what you missed, or wanting to purchase lifetime access to the first annual sjogrens summit recordings you can find them over at www.crunchyallergists.com. And while you're there, make sure to subscribe to our newsletter and email lists so you don't miss out on any future events. Like the workshop series I am planning on kicking off this summer. Thank you so much for joining us this week and I look forward to meeting with you next week.
