A lot of this world that we've lived in has like the things that we've done to this world have potentially created this beast. And so, you know, maybe it's not just like the vulnerable people with MCAS, but I think probably to some degree, we're all probably suffering from this a little bit, whether we know it or not.
I am really looking forward to talking about something that you may not have heard of today. So if you have noticed that you are sensitive to chemicals or smells or noises, or you've struggled with weird symptoms that doctors can't explain. You just don't feel good. This is an episode that you won't want to miss. We are talking about mast cell activation syndrome, which is often abbreviated MCAS or MCAS, and I can't think of a better person to walk us through this than Dr Zac Spiritos. Dr Spiritos is a gastroenterologist who has deep expertise in MCAS pots, dysautonomia, motility disorders and chronic functional gi conditions. What sets him apart is he is able to connect the dots between these overlapping conditions to really understand what exactly is going on with the patient, and then help them feel better. In this conversation, he's going to help us understand what MCAS actually is, why it presents in such wildly different ways, why it's commonly missed, and why it tends to show up alongside conditions like pots and EDS. We're going to explore the gut MCAS connection, why so many people with MCAS have persistent digestive symptoms, and how treatment has to be layered and paced to avoid overwhelming the system. If you've wondered if MCAS might explain your symptoms, or you've wondered what MCAS is, or if this is the first time you're hearing anything about it, then listen along, because you are going to learn a ton.
It really starts with finding the right team. And that person probably doesn't have all the answers, because nobody does right now, but you just need someone that will work with you and listen to you and fight for you.
Well, Dr. Spiritos, thank you for coming on. Zac, it's a pleasure to have you here, and I've been wanting to do this episode for a while, so I'm so glad that you're here to tell us everything there is to know in the next 40 minutes about MCAS. Yeah, definitely five minutes, yeah, yeah.
Well, I'm glad to be here. Thank you so much for having me.
Thank you. Give us a little bit of background about just briefly, your own journey within medicine, because there's never a straight line for a physician to end up treating MCAS?
Yeah, no, definitely not. This wasn't something that I was, like, always passionate about. I liked IBS a lot. I went to fellowship in North Carolina at Duke for my GI training, and I was like, then I joined, like, a UNC based practice, and I did a lot of IBS. Like IBS effectively, where people had a lot of symptoms, but all their testing was normal. And I loved doing that and doing that, but there was a huge component of people that I just didn't know what to do with. And they all had MCAS without me knowing what it was. And then I found out about it, and then we started treating that. But then they also had pots. And then the local pots position was booked for a decade. So I reached out to kind of old mentors from residency where I, you know, I did cardiology training, and then I learned how to treat pots. And I started getting kind of treating these patients, because they all have MCAS, they all pots, they all have hypermobility. And so I just started to kind of really hone into the unique challenges that these folks face. So I kind of have, now I run this, like Trifecta clinic. I kind of branched out and do my own thing. Now, yes, we do treat dysautonomia of all shapes and sizes, whether it's pots or, you know, just horrible dysautonomy of the gut, gastroparesis, motility issues, mast cell issues, and all things associated with EDS. But I also do like also bread and butter, gi stuff, and Ulcerative Colitis and Crohn's and those kind of things too. So that's kind of the world seems so straightforward after all of that, all sort of colitis and and Crohn's sound easy after that, right? All the algorithms, I love a good algorithm. You know, it's like, look like this, do this. If it's like less than this, do this. But man, mast cells just I my own personal algorithm changes on a weekly basis. So, yeah, doesn't play by the rules. Nope, it does not. Well for those listening, I don't know exactly what the best way is to go about this, because these patients are so complex, and you mentioned that you have that trifecta, and honestly, you got in the gut, and there's that fourth component, but you have these patients who have MCAS, who have hypermobility, who have pots. Do you have a way to kind of give people an idea of what we're talking about in in a somewhat straightforward manner? Yeah, I mean, so mast cell doesn't usually exist in isolation. It's usually there are other conditions that live with it, specifically hypermobility. And then there's a huge overlap with pots as well, and at the core of it is just immune dysregulation. And so when I see people in clinic, they often have a whole host of issues, whether it's related to hypermobility and compression disorders or joint laxity. They have dysmotility, where they have delayed gastric emptying or rapid gastric emptying, and a colon may not move, or the small bowel may not move very well, and they also have a lot of sensory issues. That's what mast cell does. So mast cell causes a lot of visceral hypersensitivity. So mast cells that live in close proximity to nerves can kind of really sensitize those nerves with various chemical modulators like histamine, prostaglandins, interleukins, those kind of things.
So my job is, I think, to kind of help people make sense of what symptoms they have, but and then create a plan for their dysautonomia, their mast cell and hypermobile related issues. And that's kind of the very kind of condensed version of what I try to do. So help us understand this. Can get very complicated, but help us understand a little bit about what's happening in the immune system, maybe specifically with MCAS, but, but if it extends into the others as well. And let me even preface that these patients are coming in with 100 sometimes different symptoms, literally, you know, like, if you name it they have it joint pain and dizziness and stomach aches and diarrhea and constipation and blurred vision. And I mean literally, if you can think of a symptom, sometimes people have every one of these symptoms, and they're often passed from doctor to doctor because they're they're kind of labeled as hypochondriacs, because one person couldn't possibly have all of those symptoms, right? But it turns out that they do, and so help us understand how the immune system is playing a role in this, this mast cell activation syndrome, this MCAS, or MCAS that we're talking about, yeah. So, I mean, I do think, you know, all of this is immunologic. Hypermobile EDS is immunologic, right? Like so the Norris lab out of Charleston, just, or they discovered, kind of the most common gene shared amongst people with hypermobile EDS, and it's, it's how the body regulates the immune system and, yeah, so and pots as well. Like, there's a huge immunologic component to that as well. Not POTS is very heterogeneous, and there's a lot of people, a lot of ways that people can get to pots, whether it's like a concussion, can do that, right? But mast cell activation syndrome is an immunologic phenomenon. It is where these mast cells, which are part of our innate immune system, they don't have any memory, they're our first line of defense. So, you know, evolution, evolutionarily, we're meant to look for threats in the environment like bacteria and fungi and viruses, and when called upon with intention, are really good, right? So they caught when they degranulate, can kind of stimulate an anaphylactic response to something that is dangerous to us. But when probe very specifically, they can release, like single chemical mediators at a time to help with bone resorption to help with healing of the gut lining, they can help with wound healing. So they have so many great like evolutionarily, had such a crucial role in kind of homeostasis and just creating this equilibrium. But when someone develops mast cell activation syndrome, they're constitutively turned on, so they're always kind of releasing some types of chemical mediators. And then there are kind of bursts of periods of time where people get more symptoms, where things flare. So yeah, and then that has a lot of downstream effects. Like, the question is, like, is that what causes hypermobility? I don't know about that, but, like, what do mast cells secrete? They secrete kinases and protein ace that can kind of tenderize these ligaments that can cause hypermobility, that can cause cranial cervical instability, right? Like, when you people develop tethered cord syndrome, and they resect the kind of phylum in the in the most distal part of the spinal cord, like they find a lot of mast cells there, right?
Mast cells can do a lot of crazy things, like, what's the implication there in endometriosis? Like, all of my patients have endometriosis, right? And there's some translational studies that say that when mast cells become overactive in the uterine lining, they cause the endometrial cells to kind of move and shift and then maybe migrate outside of the uterus. And that's obviously, like, translational studies. Like, we're not there to say, like, I don't think we're saying just yet, the masses mast cell activation causes endometriosis. But like, there's something where there's there's smoke there. So that's all to say that it's very complex. But this is all immune dysregulation. The question is, how do we get here? And that's a different that's a big conversation. Yeah, so these patients that, well, maybe I'll ask you this question. I want to summarize just a little bit, because you, you're, you speak so intelligently. It's, I want to dumb it down a little bit, the immune system. You mentioned these cells of the immune system, if they are kind of poked and one can do one thing, then they're, they're good soldiers. But if they get turned on, then they're just spitting out messengers non stop, right? And that's where a lot of these things can these symptoms can come on all the time. So mast cell activation syndrome is where patients are just feeling feeling waxing and waning symptoms non stop. First, tell us about the complexities of the diagnosis of this condition then, because that's what people are thinking, like, hi, I wonder if I could have that can I have that test? Can I can I find out if I have mast cell activation syndrome? Yeah, that's where it's tricky, because I'm not beholden to objective markers here. I just can't be right, right? And that goes against, like everything that we are taught in training, like you have to establish a diagnosis, or means some things are diagnoses of exclusion, which means that you look at everything else. And fortunately, in my line of work, people have had every test under the sun before they come to me. So it's kind of, you know, you're kind of left with mast cell disease. But quite frankly, nothing, nothing behaves this way. So I always say that the narrative informs me what's going on. So I'll tell you the narrative that I see a lot of which there's two, I think, phenotypes of people with mast cells, what I've seen one is, which is, people have always kind of been a little sensitive, like, quote, unquote sensitive, which, I hate that word, because sensitive just means, like, You're being too sensitive, right? Like they put a lot of onus on the patient. But like, no, they just, they feel terrible when things happen, when it's too hot, when they when the sounds are too loud, when the lights are too bright, and then, you know, they get, of course, they get sick, better more than anybody else.
You know, they get a vaccination, they have, like, a bigger response negatively to it. You know, heat always bothers them. Sense always bother them. And it kind of like slowly progresses. I find that to be the mind the minority of folks that I see in clinic, but the phenotype that I see the most are people that are, like, generally speaking, have been healthy for a while, like, maybe some background noise, like throughout their life, like early on, some migraines, maybe some heavy periods, but kind of things that are things that affect quality life, but don't amount to anything significant, I would say. And then something big happens, whether that's a big virus, a vaccination, big surgery, a stressful event, living in a moldy home, and then everything changes, and they become intolerant of things they used to be tolerant of. And this phenomenon is called toxigenic induced loss of toxicity, where all of a sudden you're like, I can't drink alcohol anymore. I feel terrible I can't eat like a sugary plate, or I feel like I just feel like I'm going to faint. That story is pretty unique in combination with the comorbidities, which include hypermobility and dysautonomia, whether that's a slow moving stomach or kind of a slow moving bowel, or pots, which is Postural Orthostatic Tachycardia Syndrome, which is defined by orthostatic intolerance, which means that you stand up and you don't feel so so hot, you get dizzy, you get lightheaded, you get some your heart races. And there's nothing in medicine that does this, right? So when we talk about, you know how to create what's called a differential diagnosis, which is, what do we think is going on? So patient comes into clinic, you start asking questions, and be like, Okay, what's causing this headache? So I can then order appropriate testing, right? There is nothing that does this in medicine, right? You talk about great imitators like tuberculosis and lupus and rheumatomatic diseases, and, you know, there's nothing that does this, right? There's systemic mastocytosis, which is kind of the cancer. It's like the oncologic cousin of MCAS, which is different, but have very similar symptoms. So you want to rule that out. And there's other kind of rare things, like pheochromocytoma and carcinoid syndrome, which are really, really, really, really rare, that are kind of similar, but nothing does this in terms of the symptom profile and how people got here. So I just listen to people, like, you got it. I'm happy to order testing, and I do do a little bit of clinical research, so I do get tests sometimes to see, like, I'd love to know, like, who gets positive, and, you know, what does this inform our treatment decision. I've kind of, I don't. I'm not beholden to data points. I will go after data if I am skeptical. The diagnosis of people present atypically. I have some people that just have gi a mast cell disease, where they don't have body wide symptoms. It's really just in their gut. That's where I'll get testing to kind of be like, You know what? There's a little, this smells a little mast cell to me, but I just it's not super classic. So let's get some data, and that's the minority of times, but that's when I'll get information. So it's really that clinical history with the associated comorbidities and like, history of endometriosis, history of migraines, sensitive to smells like they walk past, like if they go through Bed Bath and Beyond, like they're going to have a freaking seizure, because the smells and chemicals really bother people. Intolerance to alcohol. So all these things taken together, just increase my the likelihood that I think someone has mast cell activations. And without data, I'll just go ahead and treat people. I thank you for explaining that, that I think a lot of these people do end up in functional medicine because they've seen a doctor for every one of their symptoms, and they're kind of been treated for every one of their symptoms. But the conventional medical world is not very good at connecting the dots, right, at saying, this umbrella is MCAS, this, this, it is possible for you to have all of these symptoms be grouped under one umbrella. And so I think they're left going from doctor to doctor until they find someone who's willing to kind of step back and listen for a solid 45 minutes, you know, hear their story and be able to put some of these pieces together. Do you want to comment on that at all about why and where MCAS in conventional medicine is? Yeah, you know, I don't want to throw anybody on the bus. No, I am a traditionally trained guy, right? Functional stuff, right? I had not learned about mast cell until, like, I was on my own, right? So I don't, like, it's not like, oh, like, Joe Schmo wasn't paying attention during the mass hell lecture, like we weren't taught about it, right? And so someone comes into clinic and, like, when you are in medicine, right? Like, we put people into boxes, like, there's auto immune boxes, there's infection boxes, there's cardiovascular boxes, there's rheumatic boxes, there's, you know, and so like, when they come in, like, Oh, this is kind of the direction I'm going with this is this with this is this traumatic? Is this infectious? Is this like, so you kind of, like, there's general categories to go into mass all just bucks the trend. Like, you just, there's no, we weren't taught about this, right? And so when someone comes in with all of these symptoms, you're like, I don't even know how to categorize this person. Like, yeah, we'll work them up for like, lupus and, like, kind of the rare stuff that causes, like, these bizarre symptoms. But when that's invariably negative, you're like, Well, what's next? Like, it must be anxiety, right? Because anxiety can cause, I mean, I hate saying this, but, like, anxiety can cause a lot of somatic symptoms. Like, I've dealt with anxiety for a while, right? I've had palpitations and but it doesn't cause these kind of symptoms, right? Like, this is unique, and so when you don't know what to do with it, you're just kind of, like, you end up dismissing people. And there's also, like, a pride thing, right? I think doctors don't like not knowing the answer, right? So they're like, Oh, this must be like, you know,
go see a psychiatrist, something like, they don't really know what to say next. So I it's not like, there people say, like, I've talked to patients who have talked to providers who say ridiculous things, right? That is so.
Appropriate, and that's different. But I generally cut people some slack because, like, they just, we haven't been taught about things I don't like that. There's a lot of resistance to recognizing this is a thing which I do see. Like, I try to talk to people's doctors, like, I think this is massive. Like, oh, well, you know, I'm not sure this is I think it's an internet diagnosis. And I was like, All right, well, then tell me what else this could be, right? If you don't think this is massive, what else could this be? And there's usually not a very intelligible answer that comes back. So that's all to say that I try to get people to benefit out, but you're right. Like, a lot of this is you just need to take time to listen to people. And in traditional medicine, you're given 30 minutes of the patient, right? And then you got to triage them, and you got to write the notes. So, like, you end up like they're allowed to talk for 15 minutes, and if they don't have sufficient time, like you just, you'll be, I gotta, I don't know what this is supposed to be, anxiety. Yeah, I think you said that really well, that the conventional medical world is not built for a diagnosis like this. It flies in the face of everything we're trained to do in medicine, which is categorize and systematize and find the algorithm and find the the clone of of, you know, the set of symptoms that matches the diagnosis. And MCAS is like this big explosion of mess a little bit in the body, where it kind of crosses multiple systems in the body, and it doesn't behave the same every time, even in the same patient, you know, you might have them feel one way one day and then totally different the next day, and medicine doesn't, doesn't do very well with that. We don't, we weren't trained what to do with so much inconsistency. And so I agree with you not to throw people, not to throw the system under the bus, but to reassure patients that if that's their experience that they're getting from the conventional medical world, there are answers out there, and not to get too frustrated with your doctor. It's not that they don't care, but they weren't trained. They don't know, right? Like, people give gi doctors a lot of grief. Like, not doing more than endoscopy like, that's what gi doctors do. They do endoscopy like, that's what we're trained on. We are like, I mean, I stopped doing endoscopy like, but most of our training is just how to scope people, right? It's not to listen and go through diet and stress, like, so, like, when, yeah. And so people were like, Yeah, you just scoped me, or he or she just scoped me. I was like, that's what they were trained to do, right? Like, and so, you know, so it, I do. I wish people went like, like, took the extra step to, like, maybe what else is going on, and continue to be curious. But I think people lose curiosity over time. Like, they've trained forever. Medical training is forever. Like, it's so long and you're in so much debt, and you have kids, right? And then you're like, oh my gosh, like, how much time is there in a day? So I think it's just, I wish people continue to be curious and push themselves, and that's where I think, but I get it, like, I don't, you know, I don't blame hopefully we get there. But I do think there's another, there's another layer to this. I think is that, you know, I think I'm just trying to push the narrative, like, how to recognize this? Yeah, here's the rub. Is that it's an invisible condition for the most part. Like, there's, like, you can get rashes and things like that, but they're transient, right? It's a, as you mentioned, it organ hops, like, it can kind of go from organ system to organ system. It's variable from day to day. It's invisible. We don't have biomarkers for it, and affects young women, right? It's the perfect storm for not believing people like women are vertically not believed. So I think there's more like, more so than like, the pathophysiology, pathophysiology and how this presents in clinic, which makes it diagnostically challenging. But there's a lot of socio cultural layers to this, as well as to why it's so challenging to get people to believe these young women who are or and like, you know, women of all ages. And like, you know, we weren't taught about hypermobility in pots. Like, there's a page of it in medical training, but it's so complex. There's, like, 20 pages on peptic ulcer disease, you know, easy peptic ulcer diseases. It's a piece of cake. PPI, h pylori. Like, that's it. But like, there's no, like, there's nothing on dysautonomia, hypermobility. And so I just, I don't think it's a coincidence that, like, this just uniquely affects women. Yeah, there are men that have this as well, but by by and large, it is a female driven condition. I'm so grateful you said that. As someone who treats only women, and a lot of these women it, I'm so grateful to hear you say that exactly like that. I think the other part of what you just mentioned is, even if you are the type of doctor who is, you know, maybe you're listening to this, or you've heard of MCAS, and you're like, gosh, I should know about this. There's no easy way to go learn about it and go find out the tools that you should have in your toolbox. So for example, like you mentioned with hypermobility, if you're listening and you're like, gosh, I'm a doctor. I should know more about this. Where would you go? Like, where there's no one place to go learn how to treat MCAS pots and hypermobility, right? Like, how would someone even learn how to do what you've done? Because you've compiled and every, every practitioner I know who treats this has compiled it from multiple different resources. Yeah, it kills me. There's not, like, an up to date page on this where it's like, well, failed this, go to this. So I started big picture, and I read, never been against Occam by Larry afron. I read a few books on dysautonomia, and I wrote, I think it's called disjointed, which is a hypermobility book, and that's where I started, which kind of gives you the base. There's a lot of great podcasts out there, bendy bodies, by who.
Into Bluestein pots, cast with Dr Dempsey and Jill Brooks, a really nice place at the start. And then there's some clinical data, like no randomized trials. I mean, so POTS is different. Pots has been out there. So there are, there's no FDA approved medications for pots, but there are. And also, POTS is incredibly complex, like they're just, there's so many reasons as to why it potentially happens, but it's there's no unifying thing, so we have a tough time understanding why it's there. There's a lot of theories, and there's like seven different inputs there. So it's tough, and we don't have good biomarkers for it, but there is data there. NASA is a little bit more challenging. A lot of these are case series and pre clinical animal like, I had to go into, like, the pre clinical studies, and like how medications work, like, how does keto different work? How do glps work? Like, how does high dose vitamin C work? And if you have to read those studies to then pair presentation pathophysiology with mechanism of action medications, and kind of marry those things. And then there's anecdotes, right? You just talk to other people and see what works and what doesn't work. And then you create your own algorithms. I think we all have our own algorithms here, right? I you talked to 10 different mass cell doctors. I think we'll give you 10 different answers about how to approach a specific situation. So, yeah, I mean, it's just continue to just read a lot, but there are stuff out there. There's just not like, Great randomized control trials, which we usually love for, for use it for, for basing our decisions on Well, I love hearing you say that, because you just listed, like my own training curriculum here in a lot of what you just said. So
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Now, when you are actually getting into the treatment of these patients struggling with MCAS,
there's sort of different approaches to take. One would be in medications. One would be in supplements. One is lifestyle measures. Are.
There's some, some bullet points, or some, some, almost always lifestyle changes that people can use to really start to stabilize the body and and start to see some improvements. Yeah, I I always start with lifestyle first, even though I'm pretty sure people, most people, need medications. I don't think that's all the way true, but I think there's like, real inflammation going on that's really tough. I think that's like an auto inflammatory autoimmune condition that people are probably benefit from medications. I never say anybody needs them. It just, it's like, it's like a medication for anything. It's a tool, right? If you have a headache, you want to take Tylenol, you don't have to, but probably make you feel better, as long as you understand the risks of these therapies. So yeah, I always start with kind of remediating the environment around them and creating, like, a more kind of friendly mast cell environment at home. I don't find does that look like? Yeah, I kind of, I have this, like, very long handout that I force upon everybody, even if they don't want it, because it took me so long to make but, you know, it talked, it asked about, like, you know, it goes over, like, volatile organic compounds and synthetics and dyes and really trying to make the house more mast cell friendly, interrogating everything from the air filters to their water filters to their shower filters. You had a young woman to change her shower filter, and then she wasn't having a rash after showers anymore. It's not that always that clinically overt. I think it's more sub clinical in the sense that I and this is like my, just my my thoughts. But you know, I think that mast cell activation when you get symptoms, it's when your cup overflow. Your cup overflows, and a lot of things can fill up your cup. It can be like the day to day chemical exposures that you have. It could be the stress that you feel, it could be the food that you eat. And so these interventions just kind of decreasing your kind of the stress ledger on your mast cells. So that's where I start, and I kind of give this really long handout. I'd be happy to share it with you if you want found that be helpful. I'm not proprietary by any means. And I go to like, what deodorants are safer, like what colognes are safer, what perfumes are safer, what shampoos are safer, what cleaning supplies are safer, that kind of stuff. And then I go into food on diet. So not everybody has diet mediated symptoms, but a lot of people do. It's always a really tricky conversation, because there's no clinical data to support dietary changes in mast cell. But I do see, like, anecdotally, just two diets work over and over again, and one is the gluten free diet, and the other one's a low histamine diet, but not for everybody, right? So one diet, some people don't benefit from either these diets. Some people really benefit from one versus the other. And so I always say that this is a this is a trial and error process, and it may not make you feel better at all, and it's tough, because this is a really tough diets to follow. So I'm not saying, hey, just like, take up broccoli from your not hitting on broccoli. But like, you know, it's not just taking with one food. It's like, it's overhauling your whole lifestyle and a low histamine diet effectively, if you're a big meal plan or, like, that's kind of out the window for you. So you have to be in the right space to do this. And so if I say, like, this is what the diet is, are you ready to do this? Or do you not want to do this? I just try to give people as many non pharmacologic means of controlling this as possible, always working with a dietitian, if that's helpful, just because it's meant to be like, you remove these things as a proof of concept for a couple of weeks. And then if you're feeling better, then kind of start to layer things in maybe a low dose to see if you can get away and find a nice balance between symptom management and just being like, incredibly strict with your diet. That's a diet piece. And then I go into the stress part of things. So most people, if I probe, say that stress makes their symptoms worse. And so there's a lot of ways that we like manage stress, so to speak. You know, always talk about like, you know, their sleep and and then we talk about, like, dedicated training courses like limbic, limbic retraining, like Gupta or DNRs, which I have seen. Some people don't love it. I used to think this is, like, kind of woo, woo. But, man, people have, like, really had a lot of benefit with it if they're dedicated. So I kind of bake this in to the equation as well. If people are up for it. Some people love the idea of it. Some people like, that's not for me, and that's okay. Everybody heals in their own way. Some people want to do therapy and hypnosis and cognitive behavioral therapy. Like, there's a lot. Some people just want to take an SSR. Some people just want to take an SSRI, like, that's okay, but it's something that we always have to talk about during your your session, and then we hop into medications. And that's kind of how we layer the dialog. I think that's, it's, it's so great and and very much the way that I do it, I think one of the things that you mentioned to begin with is when we talk about lifestyle versus medication, one of the interesting things I think about MCAS patients is typically in in my patient base, we treat whatever we're treating with lifestyle as much as possible, whether it's painful periods or infertility or menopause or whatever we're trying to focus on the health foundations. And one of the things that became very apparent very quickly with starting my practice is the MCAS patients are the ones who get zero better with the general lifestyle things very frequently. So you'll be working on the gut, or you'll be working on sleep, or you'll be working on some of these other things. And most of my patients will start to see some improvement. Somehow, you know, they'll see their brains will clear a little better, their energy will get a little better, or, you know, they'll just be making progress. And then you have these MCAS patients that, no matter what I would tell them to do,
were not getting any better. Their fatigue was just just keeping them in bed, you know. And that's where you say that a lot of the MCAS patients need some sort of external support. It really.
Shows itself pretty quickly, that the typical lifestyle things just, just aren't working, and the lifestyle things you're talking about, I think, are a little bit different than what you would typically recommend, just right out of the gates with someone who has some, you know, a little bit of fatigue or trouble losing weight, or, you know, some of these other symptoms that we have. So that's that's such a good example of of where medication might be needed in addition to those other lifestyle measures you just said, are this is where things get really messy with MCAS, is what medications and supplements. So we won't necessarily go through the list, but what is your approach? How do you then say, I'm trying to figure out how to even scope. Yeah. I mean, let someone go, Yeah, that's the answer. Really. I mean, I'd be happy to elaborate. Like, my algorithm changes every couple months. I'm almost a little bit bashful about sharing it, because it may change in like, two months, you know. So I, you know? I think it starts with just understanding how medication like, so you kind of listen to, like, what has worked for people in the past, and then the why supplements work. Like, why does Celebrex work for prostate gland and synthesis? Like, why does keto different work? Like, oh yeah, it's an h1 blocker, but it's also a massive Stabler also has prostate gland and inhibition properties. And then you look into like, preclinical data and like, what flavonoids work? That's like, little yoland actually works better than quercetin, right? So it can inform your decisions. But there's also an element of randomness here. I have changed my algorithm recently
pretty drastically. Interesting. I think I'll share it. I don't know. I feel like I may regret this, but who cares? So I used to start low and go slow. I use a lot of histamine blockers. Why? Because histamine blockers work quickly. It's almost like a proof of concept, and it works in the first couple days, because you're blocking one of the chemical mediators of mast cells and histamine receptors are everywhere, from the brain to the gut to the cardiovascular system to the bones to the nerves to the bladder, so you can get, like interstitial cystitis symptoms improving with Zyrtec. It's wild. Here's the rub is that, of all the dark Thoros, I just don't find it that to be that successful. Some people it turns it around. And maybe it's just referral bias, but I the patients that I see are really, really, really refractory and have a lot of symptoms and only eat a couple foods and losing weight or gaining a lot of inflammatory edema. And it's just, it's just kind of like, they're like, if I squint, my headaches are a little better. And then what you do is you end up like layering ketotafin and chromaline and vitamin C and pea, and then you blink, and someone's like, nine medications. I'm like, are we sure we're doing the right thing here? So I also treat Ulcerative Colitis and Crohn's disease, and, God, I hope I don't regret saying this. But Okay, so in inflammatory bowel disease, you know, decades ago, we used to do this bottom up approach. We put people on pills like mesalamine and sulfasalazine, because it's, like, the easy thing to do, akin to starting anti histamines, because they're safe and, like, pretty effective. They can be effective, but people weren't getting better. So then we're like, we have all these amazing biologic medications like infliximab and HUMIRA and like, Sure, they have more side effects, but by and large, are really, really safe. And if you're comparing, like, the relative benefit for the versus the relative risk, like, the risk calculus just favors these hardcore biologics that, like, just make people feel better immediately and after, like, informed consent, like you talk about it, and people feel better. So I now use medication that I think just work better right off the bat. Obviously, talking about the landscape of medications. Talent is all trial and error, and I, you know, so I'll start with medication that I think work the best. I like low microdose glps. I think those medications are really phenomenal in mast cell disease. They're also, you know, if you look at kind of the anti inflammatory properties, pretty telling that are independent of weight loss and glycemic control, they can heal the gut as well, like, that's why they're being looked at to treat Crohn's disease and ulcerative colitis. That actually helps with improving the the intestinal lining. And it also has pretty significant benefits in the microbiome as well. And also, like, it's I find it to be best tolerated mast cell because it's endogenous, like we have GLP in our body, right? So mast cells tend to react to synthetics and weird stuff and the additives and excipients and medications, but if you inject something that we already have by and large, it's like, pretty well tolerated. So it's pretty well tolerated. It works better than most therapies, like all the Dart throws out there. Like, I find it to be really, really helpful, especially for the GI and the neurocognitive symptoms. And it's now affordable, like, you can buy it through Eli Lilly, the pharmaceutical company, and we microdose it so it ends up being pretty affordable, and it's only to get more and more affordable. But a lot of people are like, I'm uncomfortable with that. I get it. It's weird. And I always tell them, This is strange. And I would have never thought that I'd be saying this, but I can't deny what I've seen recently. So, but similarly, like, I'll just go to Lotus naltrexone. I'll go to zolair pretty quickly. If people have a lot have a lot of anaphylaxis early on. Like, I'll just go to these bigger guns, because I find that they work better. I'll be at, like, at a little like, a slightly higher risk, and then use medications like antihistamines and vitamin C and Celebrex and singular and, you know, more on like, more on the margins. But everybody's different, right? And I may change.
Just in a couple months. But I just find that it just these, these, I kind of go big and go home pretty early, considering that the side effects are pretty modest. I think that's really helpful, even just to hear, I think for patients who may be listening, or people who may be listening who are maybe new to the idea of MCAS, just to hear that, like it takes a little bit of an army, sometimes in MCAS, like it takes several different things to think about. I think is helpful to hear, and I think to hear that it's it's messy, and to kind of expect a lot of trial and error, it's a little different than if you have a sinus infection and you go to your doctor and they give you an antibiotic and everything's done, you know, like, there is a lot more trial and error, and so it does require a lot of patience from the practitioner and from the patient. Will you lay out as best you can? And I know this is also a complicated question, will you lay out any sort of typical time course? You know how long? Obviously, there are some people who you you guess that right dart right away and they get better. But even then, what's the after course, once you've gotten everything stabilized? Now, getting things stabilized with medication and with environment might take, you might get lucky, and it might take a handful of months, or it might take a year or more. But what's the what's the next step once you've gotten them pretty stabilized?
Yeah, you know, I think it's
like fortifying the ship as much as you can, preparing for times where you know you're going to flare like, I think it's probably tough to avoid all flares. Like, you may your flares just may be more modest than they were before. And then, like, create an action plan for when that happens, whether it's some Benadryl or some addor x or even a lotus benzodiazepine or Celebrex can help for like, brain fog and kind of this thermo regulatory side effects, like hot flashes. So that's kind of what it so it's like, kind of making you feel as comfortable as you can, identifying the best diet for you, and then create an action plan for when you have flares. But it takes time. And then I deconstruct the medication list, so I find, like, a lot of people are on every they're so people are so desperate to get better, so they just 1000 supplements and mitochondrial agents. And I'm like, I'm not sure these are helping. And then I deconstruct the list, because they may be making your mast cells worse. And then layer in, like, limbic retraining, if they haven't done that before, that's kind of it. But everybody's time course is different, right? And some people are so debilitated when we start and have long covid and horrible pots and dysautonomia and pelvic venous congestion. So there's all these, like, different inputs there, right? And so you just have to kind of understand the landscape of who someone is, and understanding what buttons to press when start low, go slow, do no harm, kind of educate, educate, educate, and, yeah, but it's tough. It is tough. And generally speaking, this isn't something that someone's going to be cured from permanently, like it I no longer have MCAS. I don't think so. So you're looking for ways to, like you said, fortify the ship, make make the body a little more resilient, so that when it does encounter a trigger, hopefully it doesn't have quite as deep of a dive, or it's bouncing back a little more quickly. Yeah, exactly. So you just want to make the lows not so low, and you can really, really be successful in doing so, and then just, me, know, make it seem like you're not. You know, your symptoms and your mast cell is in the forefront of your mind all the time, which you can do with some of these really helpful therapies. But we don't really have any FDA approved medications for this and so, but there are new therapies that we're learning about all the time, all the time. They're new. Even the GLP ones are very new for MCAS. I think it was, I mean, no one's been using those in MCAS for a prolonged period of time that I'm aware of, I know. I mean, about a year ago, I started hearing, you know, patients say that like, you know, I started on ozempic For whatever reason, all my my reactivity, symptoms went away. And so it's nice having these therapies, because I used to use more immunomodulatory therapies like black hole, methotrexate and things like that. And those medications have a little bit more side effects to them, you know.
But, you know, it's uh, and there's, you know, more and more therapies that we're hearing about. I'm not an early adopter, like, I'm pretty cautious, like, you know, peptides and things like that. Like, I like the idea of them, but I need a little clinical data, right? Like, so, because I think I find it so funny, though, and I know we may want to talk about peptides at some point in time, but, like, we are so we scrutinize glps so much about, like, all the things they do or don't do. But, man, like these peptides are, like, sweeping the nation. We have no data on them, right? Nothing, right? And so it's like, how do we know? Like, I just don't know, right? So they kind of, I see patients that do get better, I just don't know how they work. And that's a tough part, like, and so when, like, when to use this peptide for which patient and people, like, No, I use this peptide for, for their immune system was, like, what does that mean? The immune system is so complex, right? What part of it is it like, macrophage is a natural killer cell. Like, who do you use it for? Right? It's people that low IgA levels, like, CVID, like, what are we talking about here? Why don't we put them on IVIG then, like, I just don't know. And so I just don't like saying, like, we use it for pain, but what kind of pain? Right? And because I just don't like throwing people on medications without understanding, like, why it would work for somebody. And maybe that's I'm just very Maybe I'm just a coward. I'm a pretty cautious like, I like knowing, like I'm but also, like, I do things that are pretty unconventional outside the box, like, I use IVIG all the time, because I really know how IVIG works. And first.
Specific conditions, like, I know it would work well, and there's, like, clinical data to support it, but yeah, I just, I think I need, unfortunately, these peptides are just not being adopted by, like, the FDA, so there's not, like, a lot of there's not going to be trials in this. That's what's that's what's tough. Well, in so much of it depends on the safety of the the thing that you're talking about, the intervention you're talking about, because, for example, like Claritin, there's plenty of safety data on Claritin, so if you're using it unconventionally, you don't have to really worry, like, is it going to work, or is it not going to work? Like, I don't know, but I'm not too stressed about trying it, whereas, if the safety data is what's lacking, then you're not going to use it as willy nilly. I mean, exactly, I hope. And like, perhaps, like, when you're backed into a corner, right, and you have no other option at your disposal, you're like, look, we just don't inform consent. Informed consent, right? Yeah. And then you, you know, yeah.
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off of a loom box. You can also find it on our favorite products page at uplift for her.com now, back to the show now, a lot of patients who struggle with MCAS also really struggle with their gut with IBS, like symptoms, or just chronic symptoms, like bloating or motility issues that are just really stubborn, just not getting better no matter what they try. And sometimes that's one of the flags for MCAS, right? Is you have this gut that is just really stubborn. So where does the order of operations fit in there in terms of supporting gut healing or supporting GI symptoms. It all depends on, like, what driving those GI symptoms, right? Like, if it's you know, in this patient population, let's just take like reflux, for example.
So why does someone have like heartburn and regurgitation, right? So if they have hypermobility, they may have like, a little hiatal hernia, and it may just be a gastroesophageal reflux disease. If they have dysautonomia and they have gastroparesis, you have more food hanging out in the stomach for longer so that can just kind of sit there and bathe the distal part of the esophagus. Mast cell activation syndrome can cause symptoms that are clinically identical to gastroesophageal reflex disease, but having kind of have a less than robust response to like a traditional therapy, like a proton pump inhibitor. So, and then there's like, median, argue with ligament syndrome that causes a lot of pain after eating. So that's all to say that, like, it's tough. It's tough. Like, I really, you have to listen to someone's story, and they get a sense of, like, is this reflux disease? Is this mast cell? In the context of, like, who you are, what your studies show, what your motility studies show. So it's completely dependent on the person you know. You'll have some people with mild, mild mass cell symptoms, but goodness, their gut doesn't move. Or some people who their gut moves, well, right? And all that, it feels like their gut doesn't move, but, like all the studies show that it does move, but they have horrible mast cell disease. So it's kind of taking the symptom in the context of who they are, and then prior testing, what medications have worked, what haven't worked, and then kind of go from there. But it is, it's, uh, yeah. So it's just, it's saying, like, okay, so your symptom is, this is more mast cell? Is this more dysautonomia? Is this a compression disorder like pelvic venous congestion or MALS? And then go from there. Great. Now sometimes these patients are get pretty desperate, right? They're willing to try anything, and many have tried many things on their own. Are there any a little bit more out of the box treatments that are not medications or supplements that you found to be beneficial, things like red light or, you know, hyperbaric oxygen therapy, or anything out of the box that that is important to keep on the radar? Hmm, that's a good question.
You know HBot, like, if someone has long covid, like, again, it has to make sense for, like, what they're dealing with, right? And so what does red light do? Like, it it helps mitochondrial health, I believe, right? Like, I'm not an expert at red light, but, like, there's probably secondary mitochondrial issues in massive like, you have to, kind of, like, get back to why this works, and then use it appropriately, right? So, you know, H bot, right? It just delivers more oxygen, right? And so who has issues with oxygen delivery? It's people with, like, long covid And MECFS because of potential, like micro clotting in their vasculature. So that's how you kind of, you kind of, but there are some weird stuff that I've heard. I've had a few patients be on, like, human milk oligosaccharide, which is kind of like colostrum. Ish.
That had reduction in their mast cell symptoms, and I think it has to do with improving gut permeability. Because I do think that mast cell disease does increase like leakiness, or increase intestinal permeability. And if you look at patients like IBS D, they have a lot of increase intestinal permeability. I just think that's mast cell disease. So I think it's like indirectly improving their leakiness, which can worsen some of the GI symptoms and neurocognitive symptoms like brain fog, fatigue. So yeah, milk oligosaccharide and Kalashnikov and things that I've seen work, you know, a lot patients have like fatigue as well. And so fatigue is really, really complex, whether it's like neuroinflammation, whether it's poor sleep, whether it's not getting enough blood flow, but an eat. But I do think a lot of these patients have secondary mitochondrial dysfunction, the mitochondria dysfunction. The mitochondria, these organelles in our cells that make a lot of energy, and when the body's, like, just over stress overloaded, like, they don't work as well. They're just not as functional. And so creatine, at, like, a really lows can help with some some energy as well. So these are, like, little hacks, but again, like, I think you had to figure out, like, what's going on, right and then, and and then drill into that. But, yeah, those are some of the little hacks that I've seen. Like, Oh, that's interesting. Like, let me read more about that. Yeah, I really appreciate you saying that, because I, and I want to emphasize that, I think it's really easy as patients who are struggling to be looking for the magic bullet that's going to be the thing to make them fit subs feel better. And I think social media really worsens that, because they'll see, you know, they'll see protocols. Me crazy. You see these people that are like, You know what? If you have long covid, here's my protocols. Like, nope. That person doesn't know what long covid is because, like, that's right. There's no one so heterogeneous like that. I mean, if they've actually read the studies, they're, they're lying, right? Or they're, they're trying to sell something which is really tough to watch. And I don't speak out about an Instagram because that's not like my bag. I don't want to. Bag. I don't want to, like, ruffle any feathers, but holy smokes. Like there is a quick fix to this, everybody would feel better. It's just we're all learning here. And to say is so disingenuous and drives me crazy. Well, and not only the protocols, although that is part of it, even the patients who have been through it and they say I didn't get better. None of that stuff worked. You know, the antihistamines and the whatever. None of that worked until I found this magic bullet. And for me, that's always frustrating, because it's like, well, how do you know none of that worked? Like, who knows that that wasn't the foundation that allowed that final bullet to work, but also that was just your bullet. Like, that was just your magic bullet. And that doesn't mean, like you said, if that was the magic bullet for everyone, trust me, medicine would be on that train. That's the type of thing that medicine is good at. Is when we have a magic bullet and you use it in these circumstances, and it gets better every time, medicine would be all over that what? What makes this so difficult is that it's different for every person. The manifestation is different, the testing is different, and then the response to the treatments are different. Yeah, exactly. You know, you see these stories of people that conquered long covid or mass. I was like, This is what worked for me. Let me heal you. I was like, well, there's nothing inherently wrong with that. I'm so glad you got that. I really, really am. But it's, it's inherently misunderstanding the pathophysiology, kind of comparing your experience to other people's experience, because everybody's different, and so you need someone that sees this a lot, sees the variety, and then says, like, Okay, well, I've heard, you know, I've this core of people that really get better with this, like, perhaps, let's try this. And then, like, in a world where people are searching for answers, and I don't think anybody's trying to be deceitful, I think they're trying to do their best, but, you know, it's also just a really tricky space, and everybody's trying to figure this out. Yeah, and I really appreciate you emphasizing to the background behind it, the physiology right is thinking through what actually is going on. I think in this space there is a lot of
false explanations, like oversimplified explanations of, you know, it's all in, it's in the gut, or it's and, like, that's like, what does that mean? Really, there's a lot of things. Is a phrase that drives me a little crazy, I know, and I use it. I know what you're trying to say, but it's just like, we don't know what we're doing. We don't, like, I'm sorry. Like, just the fact that people market probiotics is just a, is just a sign that like, we just, you know, probiotics, like we think that they inhabit the gut. They don't like they really, there's no evidence to say they do. They lend really nice things to our colon, but don't, you know, they don't, it just like, so they don't really adhere to, like our microbiome. It's just like, I think there's a big misunderstanding of what things do and don't do. And, you know, healing the gut may just come down to, like, sleeping, well, eating whole foods, not drinking alcohol, not doing drugs, not smoking cigarettes, and like, eliminating stress to the best your abilities, which is obviously a ridiculous phrase in it itself. But like, I just find that, like, there's all these phrases that being are tossed around and not saying, like, healing gut is really, really important. I just it's not easy. It's not like, we like, boom, like, or we don't have a test for this GI maps mapping test. Give me a break. What are we doing? Like they're not validated? I know there's a lot of kind of back and forth there, and you may totally disagree with me. That's, that's a okay? I don't totally disagree with you. No, we just have to use tests that are validated, right? I know we're all looking for answers here, but garbage isn't is garbage in? Garbage Out? Like these microbiome tests are just like, I'm sorry, like they're not validating.
It Right? Like, what they're saying, Oh, they don't have enough of this bacteria. But, like, but for who? Right? Samuel Jackson's microbiome, his normal microbiome is much more than my microbiome. That's much more than, like, Barbra Streisand's microbiome, right? So what's a normal microbiome for you? Like, what? We don't have a normal range. When they say, Oh, I don't have enough of this. But like, compared to who, like, you go in for, like, your blood work, like we know what a normal blood count is for everybody. Things with microbiome is a lot more nuanced than that. It's not only like the absolute amount of bacteria, but like how they talk with each other, which we can't even measure. So people are desperate for answers. But doesn't mean these tests that are offered are any good, and that's where, like, I'm okay with you healing whatever way you want to heal, but I express lots of caution for these tests, because they just haven't been validated to fix anything. Validated to fix anything. Yeah. Well, I appreciate your perspective of I think that oftentimes diagnoses like this, like you said at the beginning, pots has a little more history, but MCAS and hypermobility, they're they sort of live in no man's land, right? Like functional medicine has kind of claimed them. But functional medicine doesn't, honestly, always know exactly what's going on with them. We just heal the gut, or, you know, kind of support the body in really good ways. And I practice functional medicine, and I'm, I am really proud of what I've learned and proud of the results that I get. But these diagnoses live in this no man's land, where there's functional medicine on one extreme and then conventional medicine that, like you mentioned, a lot of doctors will just poo poo these diagnoses, because there's not the consistency there to have the randomized controlled trial, like, there's never going to be a randomized controlled trial looking at MCAS, there's there's too many variables, there's too many factors. And so these patients can really suffer by not having the right team, because no one wants to claim this disease very well, and so I appreciate what you're doing is bringing as scientific an approach as possible to this really complex and complicated disease. Yeah. I mean, I think I'm okay with grasping at straws, but it has to make sense mechanistically. It just Yes, exactly. I think there's not enough, like, there's not enough critical thinking in this space. It's just kind of like, just tests, don't guess, but like, test what we don't have. I'm sorry, just because there are tests that are available doesn't mean they're good tests. And so I'm just, I'm very critical of I just, I've seen so many people hurt by tests that just, I have never been I didn't. I was never exposed to these gi mapping tests before I went on my own. And I just see them every day. And I just, yeah, I'm and there's there a lot, there a lot of money. And I just, they need to come with a big, big caution side. And I just, I just, but I get it like, I totally get it like, We're all just trying to figure out what's going on here. I just, just because there is a test doesn't mean it's a good one. No, no. Well, is there anything else, as we wrap up? Is there anything else that you feel like we've missed or that you would want to emphasize or re emphasize when talking to people who may be struggling with MCAS,
yeah, I mean, it's really tough. I'm really, really sorry that you're going through this.
I've never seen anything like this before. It causes so many tremendous physical symptoms, psychological symptoms, right? Mast cell itself can cause a lot of anxiety and depression and then, compounded with just being misunderstood by people that you really put your faith in to understand you, there's so much medical PTSD and trauma, but there are a lot of people that are thinking hard about this. We don't have great answers right now. We don't, and I really apologize for that, but there are people that think really critically about this and are trying to move the needle, and it really starts with finding the right team. And that person probably doesn't have all the answers, because nobody does right now, but you just need someone that will work with you and listen to you and fight for you. Because there's always new data coming out, right? There are new clinical studies, like they're studying towards appetite and long covid Now, right? Like there's they are. People are working,
and we have pretty good solutions right now. They're only going to get better. I know it's not incredibly encouraging, but that's kind of where it's artist. Find someone that will be in your corner, listen to you and will fight for you well and and to end on an encouraging note, I do think most of these people eventually find a way to feel a lot better, maybe not 100% better, but most people can make significant improvements, but it can be really painstakingly slow for some people. So don't give up hope, right in terms of what you're trying and keep going, Yeah, well said, well said, I want to take back my wrap up for just a second, because you said something that made me think of this is, do you feel like MCAS is increasing in frequency? Oftentimes, we have this debate about, no, we're just getting better at recognizing it. But do you feel like our current environment, and you know, whatever exposures we have are actually increasing the frequency that this is happening in 100%
100% 100%
like, I don't, you know, there are these, this theory of, like, toxigenic induced loss of tolerance, where thought is that this kind of, all the man made chemicals and exposures that people have, have really set people up for mast cell activation syndrome. And I fully believe it. I think it's.
No surprise that when you talk to these people like they're extremely sensitive to man made compounds, like, have a patient, the electromagnetic frequency from his phone sets off his mast cell. Like the like buying a new set of clothes, like they have to wash it first because all the like the stuff that's on there, you know, once they detox their house of like the chemicals and the mold, like they feel better. Maslow's just interpreting kind of this new world is very, very threatening. So I do think that's playing a big, big role. I used to not believe in any of this stuff, like kind of detoxing your home, but goodness, I am a huge believer now, because you just see people get better, and it's such an easy thing to do. I have people move to different countries because they feel so much better in different countries, because there's more food regulation in potentially other countries, and yeah, so the environment plays a humongous role in people's symptoms, but it's also like, probably not just that, right? It's probably like early life antibiotic exposure and how clean we are these days, and how that affects your microbiome and our intestinal permeability. So there's probably a lot of different inputs here, but I think we've created this unfortunately. So do you have any steps that you take yourself or in your family, or or tips that you would kind of guess at? Because, of course, we don't have any data in this, in any terms, any amount of prevention, or, you know, maybe if someone's listening and they're like, Well, I don't think I have MCAS, but I am really sensitive, and you're thinking, oh gosh, could I tip over into MCAS or something? Do you have any tips that you would that you would encourage, yeah, I mean, eat good food, right, avoid antibiotics as much as possible, unless Apple, you know, land a box, are very, very healthy. But you know, when, when used properly,
you know, get outside, play in the mud,
you know, exercise. I know these are all like redundant things, and then, you know, try to be as, like, kind of organic as possible, right? Like, we've done this kind of, like, get the plastic out of the house thing. Like, I don't know if microplastics are bad for us, but I can't think they're good for us, right? And I think being in this mass cell world, like, you know, I don't know, and I'm not environmental scientist, I don't know the science of this, but I do know that a lot of this world that we've lived in have, like, the things that we've done to this world have potentially created this beast. And so, you know, maybe it's not just like the vulnerable people with mast, but I think probably to some degree, we're all probably suffering from this a little bit, whether we know it or not, because it's ubiquitous, like the plastics and everything. But I don't know like it, but I say that with like, a big grain of salt, right? But I think I'm also very much colored by my experience in clinic, where people have been harmed by this world and they feel so much better elsewhere. So I've definitely, we have young kids, and we've kind of, we eat on like, metal plates, and we've kind of taken the plastic Tupperware out of the house, and we try to eat organic as much as we can. We also, like my kids love chicken nuggets and pizza. So, like, I don't know, like, there's a balance there. So I think it's really, really tough. I still have my cell phone. I stole my computer all day, like, that's probably horrible for me. So it's just really tough to do. But I think it's just being mindful of, yeah, maybe just try to be as kind of organic and clean as possible. But yeah, well, I so appreciate your voice of reason in this. I'm, I think it's, we're gonna keep hearing more and more about this, and I'm grateful for the work that you're doing and the research you're doing and bringing relief to the patients that are able to see you. So thank you for sharing that wealth of knowledge with us today. Yeah, thank you so much for having me really appreciate it. Thank you so much for tuning in to today's episode. A huge thank you to our guests for sharing their insights and time with us. We are grateful for the incredible support from our sponsors and to all of you listening. We couldn't do this without you. If you enjoyed this episode, please consider subscribing on your favorite platform. You can find us on our website, uplift for her calm YouTube, Apple podcast, Spotify, or wherever you love to listen. And if you found value here today, please share this episode with someone who would benefit from it. Leave us a comment or give us a review. It really helps us reach more listeners like you. Thank you for being part of our community. Stay tuned for our next episode. Lastly, this information is for educational purposes only and not intended to be medical advice. You.
