Military and Veteran Specific Tactics in Brain and Mental Health

Bryan Stepanenko, MD, MPH

So, there’s a lot of exposures that are unique to the military operational environment. Uh, when you break that down, that’s the living space, living environment, but also the training environments and the deployed environments that are a higher rates of exposure. I mean things like traumatic and non traumatic brain injuries, airborne hazards, toxic exposures that are related to either heavy metals munitions or industrial chemicals that we’re exposed to. Even things like E. M. F. And radiation exposure are uniquely higher rates than the average joe or jane. But extremophiles is a term that I want to mention and we learned the most the fastest from extremophiles from the people that have the highest rates of exposure. So a lot of the lessons that we’re learning with military population and those increased rates of what could be common exposures or more than common exposures, really give us insight into how we can protect ourselves and how we can not only look for check engine lights or early signs of dysfunction, signs and symptoms early on in ourselves, but to the people to the left and right of us. And how can you have maybe a more productive conversation about, hey, things aren’t quite right either in myself or you’re noticing those patterns in the pure person to the left and right of you. So, so really trying to make an impact not only on your own brain health and performance, but for those that are around you. And there was some fantastic…

Cheng Ruan, MD

Let me ask about that word extremophiles, some of microbiology major. So my microbiology extremophiles are organisms that live in the most extreme places on earth from Antarctica to the dead sea with the highest amount of sodium, right? And they can only be found in those environments. I guess your version of extremophiles is like the military, right? Funding extreme environments, is that correct?

Bryan Stepanenko, MD, MPH

Yeah, you got it. So extreme demands, physically, mentally higher rates of exposure to environmental exposures, lifestyle exposures. Some of these stressors, I’d say the total picture of stressors that we refer to as like a low static load. So in the functional medicine, space and community we talk about the total amount of stressors that are stressing the system. So when you talk about systems biology, medicine and network medicine, the total number of stressors tends to be uniquely a bit higher uh in the extreme filed population, that would be military population. So yeah, those lessons learned that knowledge can be translated over to civilian sector and average person listening to this podcast.

Cheng Ruan, MD

Right, so whenever, whenever we think about things in the extreme right, there’s always characteristics of these organisms that are living in the extreme that they’ve adapted to now. What are people in the military kind of adapt to this in extreme environments. And does that show up later on in their health?

Bryan Stepanenko, MD, MPH

Definitely. The acceptance of high rates of stress as normal and sleep deprivation, chronic sleep deprivation as normal, culturally normative and and socially acceptable. There was a Rand study, I believe in about 2016 that highlighted almost 50% of service members averaged less than five hours or less of sleep per night and that’s mind blowing when you think about it. They had a significantly elevated rates of co morbid sleep disorder conditions, brain health disorder conditions and chronic pain, health conditions. When you talk about orthopedic and M. S. K. Injuries, that is a norm as well and self medicating for uh what they perceive as normal aches and pains. Uh So the risk of polypharmacy is a bit of a norm as well. 

So over the counter self medication, self supplementation because of the performance demands that are normal. The acceptance of high levels of chronic stress is normal and chronic sleep deprivation is definitely a social norm and cultural norm and we’re trying to change that. So there’s a lot of efforts to improve upon some of these norms that can be degrading health and brain health and performance over time. So there’s definitely efforts but figuring out not only what the biggest impacts are, how to change that culture, but then also how to change the conversation the day to day decisions that are being made by the soldiers on the day to day. Guidance that they’re getting from the direct leadership.

Cheng Ruan, MD

Okay, so you know, earlier, you kind of rattle off a lot of different factors that can be big time. Big time risk factors for brain health. You talk about different exposures from heavy metal exposures right? To organic chemicals, inorganic chemicals, pathogens, bacteria, fungus mold. And then that combined with sleep deprivation, combined with inability to detoxify and combined with not readily available foods, create sort of this giant metabolic nightmare for the brain. So you know, how can we think about these risk factors and which ones are actually important for brain dysfunction? Is there a hierarchy do you think?

Bryan Stepanenko, MD, MPH

Excellent. I definitely think there’s a hierarchy. And I mean when you talk about supporting, when you talked about therapeutic order and trying to support brain’s ability to heal itself and the body’s ability to heal itself, there’s definitely foundational health practices that should be emphasized or you know, deconflicted or backwards plan to try and optimize now. I had a chance to build out an acronym to share with your audience. Haven’t used it before, but I think it’d be fun to use here and share with your audience. And in general it’s 10 protective strategies for brain health and a term that I’ll use is something that came from some work with a task force resilience that was part of on the military side of the house where we talk about P. P. N. And P. P. L. So personal protective nutrition and personal protective lifestyle and that being as important as PPE. So we always talk about PPE and there’s an enhanced awareness right now around PPE. Because of you know how C0V!D broke the world. But the task force was actually a directory result in response to C0V!D shutting the world down. There was a bunch of health care and human performance professionals that were like minded saying, hey lifestyle and nutrition have an important role here. We and the definitions will help you see kind of how our line of thinking got started. So just introducing PPL and PPL that’s the food and nutrients and the activities of daily living that improve metabolic and immune function to reverse disease and optimize performance. So PPL and PPL the concepts are way bigger than the content themselves. And really what I’ll introduce here is P. P. N. And P. P. L. For brain health. 

So protective strategies for brain health and performance optimization. So the acronym itself, first off acronyms in general are just a fun way of remembering things. They make things easier to mentally categorize. So when you and I are talking about, okay, you know how do we think about these protective strategies? I wanna lay it out with this fun acronym. Uh Mind sex, Mind sex for brain health. There we go. M. I. N. D. S. E. X. And I’ll just run through it real quick and then maybe we can backtrack walk through it and highlight, you know, what would check engine lights look like if this was not right. But then what does right look like and how can I either figure it out myself or where do I go for help? So starting off with the m more fiber and healthy fats and when I talk about fiber essentially aiming for about half your plate of either veggies and like high fiber veggies, Some of those prebiotic foods in particular, the roughage but also fiber containing fruits and keeping it diverse, colorful. 

We know it’s loaded with antioxidants. They’re so half your plate veggies or high fiber fruits. Keep it colorful. We know that fiber in general is helpful for intestinal integrity, motility and general gut health but also that’s extremely important for helping with those detoxification and elimination pathways, those bio transformation pathways that are going to be generally protective when we’re going. We’re living in or training in toxic environments, healthy fats in general. I always start off by saying food sources first and in general we know that there’s excellent food sources of Omega three’s mofa’s pufas, M. C. T. S and your audience hopefully is kind of spun up on those terms already. But you want to get these foods in context because there’s so much,

Cheng Ruan, MD

Mono saturated fatty acids right? In the fatty acids. Right? Okay. 

Bryan Stepanenko, MD, MPH

Yeah. So some are liquid at room temp, that’s the sofas. And that’s the E. V. O. Extra virgin olive oil. Things like the avocado oil. And then mofa’s that would be more like margarine or coconut oil. Those are going to be the things that would likely be solid at room temperature. Even even out of avocado straight up would be more in that movie category. And then the omega three’s people tend to relate to fish oil. And when we talk about healthy fish and also when you’re trying to layer in decreasing additional exposure to potential for heavy metal accumulation, there’s an awesome acronym called smash sardines, mackerel, anchovies, salmon and herring and, well I’m surprised I remember that one off the top of the head. So that acronym can be helpful for food sources of fish but in general the smaller the better, the smaller and the easier it is to consume high amounts of omega three acids. The reason I’m saying food first on the healthy fats in particular is that we’re learning so much new information about the dark matter of food and the dark matter of food in general is other compounds that either have direct health benefits that maybe it’s coming from the way your microbiome digests them and some of the metabolic byproducts of their digestion of these compounds or it’s a synergistic effect of these compounds. Plus some of the known compounds that we know in food. So really food first, healthy fats eat more fiber have to play, make it diverse, you know, make it colorful. So that’s the m if you’re ready for me to move on, I’ll jump into the eye.

Cheng Ruan, MD

Let’s go.

Bryan Stepanenko, MD, MPH

So, in general inflammatory reducing inflammation and addressing chronic infections or stealth infections. And when I talk about inflammation, I’ll narrow it down to inflammatory foods or dietary patterns as well as inflammatory substances. The substances is the low hanging fruit. That’s the easy one. That’s the smoking, which in the military community in general, um, smoking and tobacco use is a norm. Um, and there’s a lot lower rates of smoking over time that that we’re seeing, at least in our current generation. But the use of Vape is definitely going up. And I’ll just generally say, I don’t think we know enough to understand if it is inflammatory or not, the compounds and chemicals are diverse, they change. It’s hard to truly understand exactly what’s in it other than how it tastes. 

And I haven’t, I haven’t come across an anti-inflammatory Vape juice yet. So I would say those would be the substances for the foods, it’s the brown, the fried the high sugar, the simple carbs if if it’s spiking your insulin, it’s likely driving some chronic inflammation. So trying to minimize the simple carbs, the added sugars, those are things we already know. And then brown foods, fried foods, burnt foods even can be recognized by your immune system as inflammatory. So I’ll leave the inflammatory part of that acronym at that now infections uh and the stealth infections and chronic infections. This is where a lot of frustration can come from. And typically you’re gonna need higher help if you think this is an area of a problem. But some stealth infections, viral infections like E. B. V, C. M. V. And some spiral keep infections, even things like syphilis. Now I can only speak anecdotally to military population, you know, military aged males and females that are sexually active. But we’ve been finding secondary and tertiary syphilis in individuals that just never sought care. And yeah it’s either they had symptoms that went away with the initial presentation of syphilis. But clinically I can just mention that we’ve had a couple of cases where they’ve had either hand in hand lesions that we were thinking about it. So we checked or there was some kind of impairment. And the command teams were just like, we don’t know what’s going on with this kid, can you please check and then checking everything we found? And we were like wow this is easily treatable and it’s something that people just haven’t been looking for. They haven’t sought care before.

Cheng Ruan, MD

Yeah so the spirochetes like syphilis, there’s other spark, it’s to the big problem with the spire Keats, there’s non syphilitic spirochete, it’s within the dental areas as well. So dental hygiene is huge and you can actually see the same spire Keats in the dental plaques and a lot of people as well. And they literally, they just burrow into the brain. They go directly there.

Bryan Stepanenko, MD, MPH

Yeah.

Cheng Ruan, MD

And so that’s probably the more common type of spirochete that a lot of the holistic biological dentists they will literally put the plaques in the slides and I’ve seen my, because I’ve had spirochetes before. And they’ll look at that and it’s, it’s literally like spiraling around like a course food. It’s moving at a really high paced under a microscope mel, but those that do like actually burrow into peoples brains over time if people develop Alzheimer’s and then on autopsy you can see the same living spire keeps that are actually in the brain as well. And so the dental dental health is huge as well, especially the spirochete.

Bryan Stepanenko, MD, MPH

I need to start associating with some biological dentist. Maybe a link of how we can find where we go. And then the other area of infection that will cause a lot of problems for individuals can be the intestinal parasites and military community in general. We chalk it up to travelers diarrhea but they’re, they’re over in deployed settings or in foreign foreign countries eating local water, drinking local sorry, drinking local water, eating local meats and bathing in in local, you know, water and they come across with issues that hey, I’ve never been quite the same since that deployment are never been quite the same since that intestinal infection. And there was some, an interesting study in Polish soldiers that were deployed to the same Iraq and Afghanistan regions that our soldiers were, where a surprising number of them were coming back with giardia and Jordi in particular with the majority of the number that they found being asymptomatic. So when you start talking about intestinal parasites that are either non compensable or potentially non compensable meaning like they might not be supporting your health. They may actually be causing problems for your intestinal health or general health. Girardi is up there at least with the military population even asymptomatic or not previously symptomatic. 

Cheng Ruan, MD

A lot of these parasites that they hide and then they cause just like a slow level like the immune response. The release just histamine over time, which makes people have like brain fog and fatigue right? And these parasites over time like disrupts the hormone balance lowers the testosterone and military personnel, you know, and military women, it blocks progesterone receptors. So all these receptors are things that make the brain function well and that could be caused by low lying parasites. Now, the only reason I know that this is because I started looking for them uh in, in people either an active active military duty or recent deployment. right? And they come back and it’s a surprisingly high number of people that actually have this. And the regular parasite test that we get can’t even find it is a problem with more specialty microbiome test. Do you find that as well?

Bryan Stepanenko, MD, MPH

Yeah, you’re nailing it. The standard tests don’t find it. The history and the person in context over time just screams, hey, something’s wrong right around this time frame right here and it’s been wrong ever since. And the standard tests just aren’t picking up on it. So I love that maybe… 

Cheng Ruan, MD

You maybe feel that came and I’ll never gosh, I’ll never forget this. And he was never right after deployment. But he basically long story short had developed Parkinson’s syndrome. Tremors whole nine yards. I mean he was just 40 years old. Pretty young, Right? And so long story short turned out to be a parasite that’s actually is a nasal scientist has been there for years, for years, right? And I have to give a lot of credit to the dentist and E. M. T. Doctors for even culturing that. And uh and he had to get surgery, surgical removal of some of the necrotic areas that the dead areas there. But my gosh like, you know, maybe two weeks after surgery. This guy’s like a different person. He’s like vibrant. He’s not depressed anymore interacting with his kids. It was such a beautiful thing to see for transformation process. He didn’t have dark circles around his eyes anymore. And so parasites are a huge deal with. And I’m starting to realize that in the military population so happy that we’re talking about it. So people were listening to this. Most people listening to this probably either is in the military wasn’t military or has family in the military who are listening to our this but if you have family members who have friends that experiencing kinds of issues like these infections are so hard to find but really take some dedications to to keep going forward and not give up especially when it comes to neurocognitive issues. You know.

Bryan Stepanenko, MD, MPH

Yeah neurological brain and cognitive but then also inflammatory based and like immune based issues. Whenever that gut hasn’t been right since especially if it’s around employment like go get checked out and consider some specialty lab testing because standard lab testing available through military health system like doesn’t always show it. Same goes for Lyme. Lyme is another one of those that can cause a lot of frustration because the standard labs, the standard screening assessments like don’t always catch it and if it’s uh walks like a duck smells like duck, talks like duck. You know then it’s like hey okay maybe I should do a specialty lab access from here.

Cheng Ruan, MD

Lyme disease is called the master mimicker of health similar to syphilis and they’re both spirochete so she needs the under microscope. They’re spirals. So Lyme disease can look like anything. And a lot of times you know people are diagnosed with psychiatric conditions align the disease bipolar disorder, schizophrenia and the people who have an active combat get diagnosed with that more readily than those who haven’t right? Because they kind of you know chalk it up to be in a combat veteran or something like that right? And we found a lot of these people have actually like Lyme disease and all these different things when you get treated they get significantly better but I’m so glad you mentioned. That was awesome.

Bryan Stepanenko, MD, MPH

Yeah you can’t talk your way out of those issues right there just you know. Alright so nutritional deficiencies is the end And nutritional deficiencies and military population in particular. Uh there was some studies that showed at least 70% of military individuals that they that they include in the study were vitamin D. Deficient. Like deficient less than 30. Now vitamin D. And magnesium tend to be ones that across the board we can say hey there’s lower sources and food If you’re not regularly eating higher magnesium foods uh dark leafy greens and getting out in the sun or taking vitamin D. Supplementation then across the board you can kind of start safely there. But there’s other nutrients micro nutrients in particular that I want to highlight some relative insufficiencies that are important to address because it’s the difference of going into a toxic environment and being a sponge versus building your building your force field and making sure that some of those heavy metals or other toxic exposures don’t don’t cause a problem. Things like zinc selenium B vitamins. And yeah so I’m a kind of backtrack on that one but zinc selenium and B. Vitamins in particular even iron. And calcium can be relatively insufficient especially if you’ve been treating chronic acid reflux. Especially with over the counter acid reflux medications or even prescribed acid reducing medications for years. Relative insufficiencies here will create gaps and needs for either two plus or three plus ions that heavy metals tend to look exactly like that And let’s just use the example of vitamin D. Deficiency or insufficiency. So if your vitamin D. Insufficient or deficient and your calcium is coming from bones. So there’s high bone turnover rates and there’s a relative insufficiency of calcium in your body and you’re doing a lot of range time and you’re getting a lot of lead exposure. Then your body will look at lead as calcium and immediately start putting it in depositing it into your bones because of that high amounts of turnover already. Now one protective measure here is just making sure you’ve got plenty of vitamin D. 

And it’s not just sufficient, it’s it’s optimal that we’re aiming for. So just using vitamin D. As an example to where that calcium metabolism can create a need and can be leveraged for protection if you just have enough. So I just wanted to kind of highlight that one as an example. Yeah. So that’s something that could easily be addressed with a high quality multi multivitamin and vitamin D. Something like 9000 iu per day. And that’s super state starting point. But that’s just checking off all the boxes. And once again that’s the difference between whether or not you’re going to be a sponge or have your force field built up going into these environments. And that could be the difference between a good outcome and a poor prognosis after a traumatic brain injury, things like that, you know, your brain’s ability to heal. Uh Next I was going to roll into this bio sis and when I talk about this bio sis in particular there’s kind of three main categories I tend to talk about with my patients. Candida in particular fungal overgrowth.

Cheng Ruan, MD

Defined despite this first, what’s your definition of?

Bryan Stepanenko, MD, MPH

So that can either be unfriendlies in the intestinal track or friendlies in the wrong neighborhoods. And I try and like so and I use an analogy of cats that I’ll mention in a second here. But yeah, in general I really just mentally categorized into those two buckets and say that hey unfriendlies in the wrong neighborhood is like cats when you start feeding them at your front door. Like what happens when you feed stray cats? They multiply and it’s almost like they tell other cats that hey food’s here. So you start getting cats around the neighborhood when they really shouldn’t be. and that’s the analogy that I talk about when we’re setting the stage for intestinal small intestinal bacterial overgrowth, it can even be healthy bacteria that should be in the large intestine that is just baited and given food sources higher up in the track and that’s feeding the cats higher up in the tracks. So they’re over populating in the wrong neighborhood and that itself can cause a lot of problems. So Candida, fed by simple carb foods, added sugar foods. And foods that Candida actually will stimulate your body to crave more of uh in the setting of high fungal burden historically. So athletes, foot jock, itch, maybe they’ve got some thrush or a little coating on their tongue and they’ve got some rectal itching and maybe they’ve got some good stuff and some sugar cravings and you know, we’ll consider it. So that’s something that you kind of test for, you can start some dietary strategies and some herbal and nutritionals to nutraceuticals to try and address that and Candida is one of those.

Cheng Ruan, MD

Whenever there’s this, this biases can lead to overgrowth that signals to the brain to, hey give me more bad stuff. Can you give me more, the more of the stimulating foods and this is why people are addicted to like Doritos and Cheetos. There’s so much msg and msg is really addictive plus there’s processed cars in there and that stimulates that dopamine to continue to drive but that cause major like insomnia, worsens PTSD for those who experienced it, the worst is bipolar disorder, emotionality. Right. And so yeah all those things man, they come from the impairment of the bacteria that’s in the gut and even on the back Obama, even the sciences as well. You know there’s so many things that affect like the gut bacteria outside of food as well right. And one of the things that I want to ask you about is overtraining, overtraining is one of the major stimulators of this bio sis and gut bacteria. Right?

Bryan Stepanenko, MD, MPH

And so yeah, yeah.

Cheng Ruan, MD

So what is that like in the military population, do you see people like just being pushed to like a lot of training and then they come back and all of a sudden you have to sort of exposure as you have this for this uh this bios Asus going on and they’re bloated and brain fog fatigue afterwards. What is that like?

Bryan Stepanenko, MD, MPH

Yeah, so notoriously there’s certain training environments and training pathways that will push people beyond the max and it’s literally to find their limit and it’s all voluntary. So people are able to quit at any time, But it’s that mental fortitude that will mental fortitude and being part of the group of others that are looking at you as like don’t you dare quit to where people will push themselves beyond their their body’s ability to to recuperate as fast as needed. And everyone’s you know different on the spectrum of God help to start off with. So yes intestinal permeability. Well there’s studies that have shown during phases like ranger school during phases like going on 20 mile ruck march is that there will be intestinal permeability at the end of that. And this bio sis can definitely. Well you know the resultant of that I don’t have that awareness on the literature but there is a D. O. D. Microbiome consortium that is thinking on that doing studies around this and they’re looking at these extreme environments for performance, extreme environments for environment and how that impacts the microbiome. So there’s some really exciting stuff that they’re doing there. And if there’s an opportunity to share that with you I’ll try and share that with you in the future here now. 

Cheng Ruan, MD

Amazing. Awesome.

Bryan Stepanenko, MD, MPH

An interesting thing around that is that the intestinal permeability that results from this high physical demand that can lead to food sensitivities. For some of the common foods that we use to refuel and basically recover from those intense performance periods. So things like dairy and egg quite literally may be very common food sensitivities that you’ll find if you look for them and it might be the body’s normal adaptive response to this overtrained period where there was intestinal permeability transparently. So yeah, you might find some interesting food sensitivities there. 

Cheng Ruan, MD

That was sensitive at that time, but not necessarily in other environments? right? 

Bryan Stepanenko, MD, MPH

Right.

Cheng Ruan, MD

So, and we see this so much in insomnia and PTSD in the general population. So if I were to test somebody who’s super irritated as really bad PTSD their lives will be positive for everything that they react to and food, but in times of like home and distressing or or go negative and we see this because our body is always a moving target, you know, and it’s sort of this misconception is tolerant to this food. I’m intelligent, this food forever. Well not necessarily, you know, And uh and we have to appreciate the bodies for the ability to kind of come back and fight back, you know?

Bryan Stepanenko, MD, MPH

100%. Yeah, there’s plenty of things that we can tell the immune system to calm down, stop being over reactive and stop being self reactive and rebuild the gut integrity because that gut integrity can bounce back pretty quickly, as long as it gets the right nourishment and the right time to relax, recover. So yeah, the we talked about setting the stage for small intestinal bacterial overgrowth. I think lactose intolerance is one easily overlooked and commonly overlooked thing that can set the stage for something like small intestinal bacterial overgrowth or even Canada. to where you digest that lactose poorly, it’s now a viable food source all throughout the small intestine. Baiting some of that bacteria from the large intestine and feeding some of those fungal components like Candida that feast on some of these sugars, these natural sugars. That’s interesting. 

Cheng Ruan, MD

Let’s break that down for a little bit. So for those of you listening, small intestinal bacterial overgrowth. So in our gut we have the stomach, we have the small intestine we have the large intestines. So the majority of these bacteria supposed to exist within the large intestine, the small intestine for the most part doesn’t have any organisms or very few organisms in it unless there’s times of high stress or eating inflammation, then bacteria will over grow into those areas. as sort of almost like a compensation mechanism. The first mechanism is that whenever in times Of stress or training there’s less blood flow to the gut. And so there’s less digestion, there’s less stomach assets produced. So when people are eating on a run and the faster you eat, the more blow you get. Well that’s because bacteria tends to over grow in the small intestine and the byproduct of some of the bacteria is gas such as hydrogen sulfide or methane. And so what we’re talking about is the mechanism that’s really behind this. So yes, training is a big part of it right, eating poor quality foods is part of it eating inflammatory foods as part of it. 

You know, Cheetos probably doesn’t doesn’t doesn’t help you know, either, right? And then eating up and not just that, but alcohol consumption actually makes that a whole lot worse as well. And then popping Tums just makes it worse later on as well, which I see a lot of that inhabits. So yeah, absolutely. But you’re right this and and you know, work connects to the brain. Is this So these small intestinal bacterial overgrowth than in turn these gasses gets created, this method gets created. It actually stuns the gut. Right? So Well that’s a shame because the if the gut is stunned that the gut cannot activate serotonin. And so people get focused on dopamine, which is the neurotransmitter excited to transmitter, right? It’s also the angry and emotionality no transmitter as well. And so this is where sort of that bipolar, you know, labeling kind of hits is that people have sort of this bipolar tendencies of depression and mania. And there’s a lot of like gut issues. So yes, like healing the gut issues can resolve a lot of these bipolar tendencies as well. And so and this is I think this is just really heavily missing within all of the psychiatry is that we really need to focus on, not just labeling them a disease and give him a medal and send them home and figure out what the root causes is going on. You know. But you know that’s the reason we have these summits but yeah go ahead. 

Bryan Stepanenko, MD, MPH

Definitely. The other understanding that try to arm my patients with is what is a microbiome disrupting event. So if they can understand that a intestinal infection or an antibiotic course especially six months or nine months of antimalarial doxycycline Something like that where they get an antibiotic exposure or intestinal infection. There’s a unique opportunity for dysbiosis right there. That’s a microbiome disrupting event. And when you talk about these intense physical performance training demands that that could generally be classic. You know categorized as microbiome disrupting event as well. And once again that D. O. D. microbiome consortium is likely going to come up with some good information about microbiome disrupting events in general. So whenever they can identify a micro microbiome disrupting event then how do I support uh you bios is and how do I support good microbiome health right around that time or at least recovering and rehabilitating it. 

Now there’s some conflicting information about whether probiotics would be helpful during the actual either intestinal infection or the antibiotic course. But there is good evidence that talks about friendly fun guy like sacrifices Belardi that are antibiotic resistant. And that could be started at the same time. So as you’re taking the and let’s use antibiotics as the specific example. As you’re taking the antibiotic course, you can jump on a probiotic that contains sacrifices Belardi friendly fungus because it’s relatively resistant to some of those uh those antibiotics. But you could also start a prebiotic focused dietary regimen. So you can incorporate more probiotics and that will help support good healthy microbiome that’s present, whether that’s still trying to recover and you can repopulate with essentially a friendly fungi containing probiotic. Now, once you finish the antibiotic course, I usually focus on at least two weeks of at least 10 billion cf you per day. 

And the sources can be diverse, but we usually get something something prescription greater over the counter and at least 10 billion cf you for at least two weeks. Once again with military population. I think the frequency of microbiome disrupting events is so high that you want to create a good foundational base that has both healthy fungi as well as healthy bacteria and as a foundational base for the microbiome. So in creating a resilient and resistant microbiome, I think that that healthy fun guy is something that we’re going to start hearing more about that I definitely talked with about my patients.

Cheng Ruan, MD

Yeah, so glad you brought up sacrifices Belardi because we know that supplementation has a massive effect on mental health improvement, mental health and quality of life, it actually decreases chronic inflammation, chronic pain as well, decrease oxidative stress. And they actually did these studies on some pretty end stage brain disorders like multiple sclerosis and Parkinson’s as well. So we know there’s a gut brain connections, right? We talked about the microbiome disrupting events are the same thing as the brain disrupting events. There’s no difference. You know, that’s really important to know. And the same thing that we’re talking, healing the gut is gonna heal the brain as well over time. And so I’m really excited to get this out to the military population. because I said extremophiles, right? Living in extreme environments, going onto a tremendous amount of stress doing things that regular people do not do. I think this is this is certainly the one of the most important topics that’s not talked about, you know, very frequently and I’m so glad that you’re one of the few that’s on board to talk about it. 

Bryan Stepanenko, MD, MPH

Definitely. Hey, one important disclaimer that I want to make that I’d love to ask your team to kind of put up front uh as much as possible is that the views and opinions I expressed are my own, they do not represent that of the D. O. D. The military health system or any governmental agency. So just once again, want to want to highlight that, I’m speaking from my own personal experience my own personal perspective, my pleasure just for time situation. Where is how we doing? I can blast through the last three and then. 

Cheng Ruan, MD

That’s good let’s go.

Bryan Stepanenko, MD, MPH

All right, so the next one is being able to track your sleep and stress on wearable tech. so things like Garmin watches or rings, um, there’s plenty of other other options. Whoop is another device that we’re seeing some groups use in the military community. Now anything that can measure and evaluate accelerometer. Uh so whether like your step counts or movement throughout the day or even throughout the night. Um, so movement H. R. V. And an added bonus if it can track oxygen levels at night time as well. Uh so I’m bringing these three capabilities up in particular because they’re being consolidated to create composite readiness metrics and composite kind of recharge recovery and readiness numbers that you can look at each morning and make a decision of how hard should I go today. 

How well is my body recovering from what I did the previous week, the previous day is and it gives you such good insight to see yourself on the impact of the decisions you make day in day, out of what you eat, what you don’t eat, what you do and how you recover. Now quantity and quality of sleep is dependent upon. You know how stressed your body is throughout the night as well. And in the military population there is such a surprising incidence and prevalence of sleep breathing disorders in fit, otherwise fit, maybe even like extremely healthy appearing individuals. There’s sleep breathing disorders, especially in special operations community there where they’ve got a tremendous amount of like blast overpressure exposures and traumatic and non traumatic brain injuries. Uh the risk of and the impact of sleep breathing disorders is such that you want to identify it if it’s a problem. And my threshold for sleep studies and probably stenography is like ordering a sleep study on those individuals is extremely low because I want to know if it’s a problem. I want to know that’s it’s significantly undercutting our ability to heal and our ability to improve brain health or maintain it over time.

Cheng Ruan, MD

Yeah, the sleep studies are something that I think everyone should get almost like as a before even joined the military. I wish, I wish that’s one of the screening tools because and breathing disorders and obstructive sleep apnea is loading comments, one of four humans, Right? Um, and so that’s probably understating it because, you know, our jaws have changed in the last 200 years. Our sciences have changed the last 200 years. The structures of our face has changed over the last 100 years. So because becoming much more prevalent in the population and now we’re understanding that it may be very independent of um, obesity weight gain large necks and stuff like that. It’s because there’s other soft tissue structures within the oral cavity and the nasal cavity that can create obstructions and even in the trachea as well. And so this goes back to my story 2018. We actually did brain mapping with quantity EEGs. On the PTSD population from the V. A. Hospital here in Houston. And we had this whole program that we actually did just just brain screens right within the PTSD population. So we have over 500 people on those cans, right? And 500 out of 500 actually had obstructive sleep at.

Bryan Stepanenko, MD, MPH

Yeah. That’s ridiculous.

Cheng Ruan, MD

They already get this, they’re already diagnosed with PTSD. They already they already diagnosed with mental health disorders. So this is sort of the population that the medicine didn’t work right? Therapies didn’t work right? The group sessions didn’t work right? The peer sessions work. So we’re talking about the actual population and guess what we want to treat the sleep. A lot of them get significantly better. And it’s really rewarding to see That really opened my eyes. I’m like Oh my gosh, I think everyone should get screened with a sleep study prior to going to have to come back. You know, I think that’s really cool.

Bryan Stepanenko, MD, MPH

100%. I strongly support that, especially after hearing 500 out of 500 that’s like impressive. Oh boy. Alright. So yeah your ability to see yourself readiness recovery, nighttime sleep quantity and quality critical for brain health and performance and ability to do that with wearable tech. Even just to see trends over time that provides you the opportunity to self experiment and make some different decisions. You get to see the impact of whether you do chewing tobacco or not before bedtime, whether or not you know how you sleep and how stressed your body is after a drink or two before bedtime. You know, do you really want to have those 2 drinks before you have to go be, you know, ready for optimal performance the next day if you know that hey, your response to it is this throughout the night and how you feel the next day. So yeah, you start attaching data to how you feel and the mental clarity and the physical and mental performance the following day and you get to make some different decisions with good information. 

So next area is elimination habits and when we talk about protecting the brain from some of the toxic environments or the training exposures, the deployment exposures, making sure we’re not a sponge and that we’ve got a force field that we’re building up. You want to ensure that bio transformation pathways and elimination pathways specifically the urine sweat and stool are flowing well that the exit pathways are unblocked and things are going good. A lot of individuals, not just military population, walk around chronically under hydrated or even dehydrated now think about how often you walk around with some dry mouth chapped lips, um, you know, knowing that your bottle of water is sitting at the edge of your desk, but you haven’t touched it all day. You know, that’s just a byproduct of our busy lifestyle here and oversaturation with tasks. However, that directly translates to your ability to make urine offload metabolic byproducts to sweat and sweat efficiently and effectively. 

That’s ways we get rid of some of these industrial chemical byproducts that your body has metabolized successfully and is now trying to eliminate. Let it, you know, help your body get it out of the system. And um, with regards to uh, a goal for hydration for an active community, for the military population, we say, hey, take your weight and pounds divided by two. And that’s your goal for ounces per day. That’s a good starting point. If you don’t know any different. And that’s a great starting point. But once again, knowing some of those symptoms of relative low hydration status, um, that’d be good and the color of your urine in general, it shouldn’t be so dark. Uh, it can be a little bit colorful, especially if you’re taking your daily multivitamin, but by all means it shouldn’t be, you know, brown or dark orange. Now, stool in particular, we talked about fiber and for a goal of fiber, We talked about 25 to 35 g of fiber per day diversify the sources of fiber. And plant based fiber, you know, vegetable based fiber is excellent food and context is a great starting point. But in general, have you heard about the sesame seed test where essentially yeah, a way of checking of either how constipated you are, how good intestinal motility is. You take half a teaspoon or a teaspoon of sesame seeds, you see how long it takes for your body to eliminate it and come out the other end in general. In general, you know, really good is less than 24 hours to start seeing some sesame seeds. Now if it’s approaching 48 hours, you haven’t seen any sesame seeds, like you just start asking your questions of why do you need more fiber? Do you need more fluids or movement? Fiber fluids? Movement can help things along and if you’re still unable to improve things, get help, ask you know, ask questions, seek out clinical support and find out, you know, what’s going on. How can I support gut motility? Is there any blockage I should be aware of? Help me look. So yeah, unblocking that the stool and exit strategies for those bio transformation pathways.

Cheng Ruan, MD

So one of the most compelling reasons for hydration in school is that anybody listening is a runner. You know that if your gut is not right, your split time is terrible for running and actually it has to do with reaction time and brain function as well. And so if you’re dehydrated, just just by, you know, 20% dehydration by the way, most people walking around these days where 80% of people walking around these days are dehydrated, right? You know, And uh and even with just 20% of dehydration over 24 hour period, the reaction time and the human reaction time, visual reaction time increases by 400 milliseconds. That’s a life or death decision making process, you know, with the military operation. But more importantly, the longer you go dehydrate that that doesn’t just limit your goes exponentially goes up in terms of the reaction times. So it’s longer for you to react. So that’s a very huge issue. You know, water and hydration is so crucial to to the human body. And there’s two reasons for that one. 

Okay, we can understand, okay, well, good water is good for me and it helps hydrate me and stuff like that myself can work right? And to, this is more of a recent discovery, um, adequate hydration is the only way you can flush toxins from the brain called the lymphatic channel and lymphatic channels. Yeah, they mirror the guts. So if you have like leaky gut, you have like leaky brain the same the same construct. And when you have got this bios is leaky gut, those lymphatic channels in the brain, they look almost identical. And these cells for exercise, they just get bigger and bigger, bigger, more things filtered through. And so these toxicities can build up in the brain. And then what happens over time is you go, you go into deployment and boom, Something happens, right. Whether it’s concussive injuries from the brain injury, right? Or the injury doesn’t happen in the brain. Maybe it’s lim wounds, right. Your immune system just revs up and then the brain just goes into this like napalm effect of auto immune response. And this is where the brain fog can really occur. This kind of what happens with C0V!D 19 when when humans are exposed to the spike protein on C0V!D 19, we’re seeing these post C0V!D syndrome and it’s similar to systemic inflammation from people who are already triggered to be inflamed in the first place. Right. And this is so important for people, you know, prior to deployment to really understand that I just can’t stand how, 

Bryan Stepanenko, MD, MPH

I love this conversation how we’re talking about hydration from a both a brain protection and brain performance perspective, especially the studies that you were talking about with the adequate hydration leading to a 400 millisecond difference and decision making time. That’s huge. Thanks for mentioning that that’s impressive. So, last one being exercise. so that’s that’s my ex for the MINDSEX acronym is that exercise? Two things in particular. So I mean yeah we know the general recommendations that moderate intensity for most days per week, at least five from previous recommendations for like cardiovascular type exercise and then vigorous intensity or or resistance exercise training for at least two days per week. There is some overlap of the protective benefit and the metabolic benefits from both cardiovascular exercise and resistance exercise. And you’ve even got blends or types of training regimens that can hit the benefits of both. Like high intensity interval training uh to where you can get cardiovascular benefit as well as resistance exercise benefit. But in general anti inflammatory it increases antioxidant capacity. And the increase in that BDNF brain derived neurotrophic factor which is miracle growth for the brain. You’re not only doing brain protection.

Cheng Ruan, MD

Yeah. Yes.

Bryan Stepanenko, MD, MPH

Yeah. So the metabolic impact, the brain protection and brain performance impact of exercise is just something that can’t be understated. So that benefit sticks around for 48 and 72 hours. So at least one bout of exercise every 48-72 hours. And once again you can get creative and you can minimize time and even equipment necessary. Things like to Bottas things like high intensity interval training can really be uh one stone and several birds like you can minimize that time and equipment burden. The other thing that I’ll mention is that, yes, you can definitely overdo it and we talked about it, the training pathways that attacks the individual to where there’s a detrimental impact transient lee on gut health, brain health, overall body health, hormonal balances, metabolic function like across the board. That’s where being able to track your sleep and stress matter. And that’s where being able to see your composite readiness metrics in the morning matter. And that’s where being able to make a determination. 

Hey, is today where I go from my pr or where I go for that really long run ruck. Or should I find a more restorative uh restful recovery type exercise going for, you know, walks outdoors more of a stretching and self care regimen or should I go sit in the hot sauna for some cardiovascular benefit instead of really pushing it to the max today. Um, so being able to track with that wearable tech can definitely help you understand if, if you’re at risk of overtraining or you’re currently in an overtrained state and you need to rest and recover uh and prioritize those. That’s kind of the big deal on exercise here. But I do want to highlight another opportunity for physical activity and specifically mindfulness based physical activities, Things that require intentional focus and cognitive, high cognitive demand in order to perform things like archery, things like golf, things like table tennis. I’ve even had patients that did bowling and that was like an enjoyable hobby for them but we identified it as their mindfulness based physical activity that they could use as a yardstick. 

They could use as a yardstick for determining whether they’re having a good day or a bad day and whether they could track progress over time. So they then utilize that as yeah. Hey we’re doing these interventions, let’s number one get you back to it and doing it regularly because it’s something you enjoy. We’re gonna prioritize joy. That’s an easier way than just trying to distress. So rather than just focusing on minimizing reducing stress, we’re gonna focus on prioritizing joy, putting it on the calendar. What’s something enjoyable that you’ve done in the past and its dual purpose or even triple purposes activity. So for me I always try to identify what’s that mindfulness based physical activity that you do or have done that you enjoy that we can use as a yardstick and we can get you back to doing to assess yourself but also track progress over time. Do you have any specific examples that jumped out to you? Something that, 

Cheng Ruan, MD

I’ll tell you what. I think there’s a lot of research done with some of these activities, especially like tai chi and qi gong with the Chinese martial arts and you’re not just bringing mindfulness, you’re bringing breath to it as well and we’re seeing amazing amount of data for increasing BDNF literally that you can increase thing that grows your brain by doing some of this stuff sometimes a lot more than uh than that hit exercises and in high intensity training as well. And so there’s I think there’s multiple reasons for this one. It kind of goes back to the lymphatic channel, talked earlier where the brain is able to detox to sort of these circular type movements and then to the breath. I think most of us kinda breathe in with our chest up and then raise our shoulders, take a deep breath and reality the true deep breath is expanding your belly out. Right. So a lot of these exercises require like belly breathing to move the actual air, which has huge physiological changes in the brain, massive changes in the brain. In fact there’s studies showing that breath techniques change over 100,000 gene expressions for the brain after about five minutes of a specific breath techniques. 

Right? And so this is absolutely huge and developing that resilience before deployment is super preventative for a lot of things by developing that that brain resilience. So another interesting that came up is that so some of the stuff you’re talking about golf and specifically and talk about bowling and other stuff that actually shows improved the cerebellum connection. So cerebellum is part of the part of the brain that sits under the major part of the brain, the cerebral cortex and the cerebellum. What I was taught was like the balance center of our body, but actually it does a whole lot more, it coordinates the rest of our heart cognitive order systems. So cerebellum training has been huge implication uh in like PTSD uh early cognitive uh and stuff like that as well. And so I think there’s a true purpose to these intentional exercises in that we’re actually engaging higher order thought process brain rather than just, you know, running in and stuff like that. So I think that’s an amazing thing. 

Bryan Stepanenko, MD, MPH

Real quick on the topic that you’re mentioning the cerebellum activity. We had a cerebellar expert from Stanford Brain Performance Clinic talked to a virtual learning collaborative that we had on warfighter Brain health and he explained it very simply that the cerebellum its job is to predict and coordinate and it predicts where things will be at in space and where you’ll be at and your body will be at in relation to that in space and time and its ability to predict is relying on your ability to focus and pay attention and then its ability to coordinate is based off of brain connections and and neural connectivity. So by all means its integration into every function is extremely important and such a window into brain health and brain performance that can change minute by minute, hour by hour day by day. So there’s a fantastic opportunity with some eye movement tracking technology. Just two companies that come to mind that I know that are used in some of our circles is right. IQ and I sink by sink.

 Think both of those technologies have been incorporated but it tracks eye movement, technology, movement and ability to track. But really what they’re assessing cerebellum function, your ability to maintain attention and focus, predict. You know incorporate that information into your cerebellum, cerebellum and the simple action of following a target. So I think that’s something that we’re going to see utilize more to assess readiness prior to high demand activities. No fail no fail activities. And that can be a window into brain health that might have been impacted by poor sleep the night before, two drinks, three drinks the night before. What you ate for breakfast that morning. Like little things can impact your cerebellum and brain activity. And we can see real time changes with some of these technologies. Yeah the such a long way, yeah that individual brought up another thing that I think is extremely helpful and important that we’re gonna see some changes in practice with post TB. 

I return to exercise specifically return to cardiovascular exercise. So at that Stanford brain performance center. They have their collegiate athletes come in typically within 24 hour period of a traumatic brain injury from whatever uh whatever sport they play. They’ll get into the center and get on a stationary seated bike and they’ll start doing some cardiovascular exercise. That we know reduces inflammation, increases antioxidant reserving and capacity. And once again that BDNF component goes up. There’s some endothelial growth factors that also help support that recovery and regrowth of not just the nerves themselves, but the vascular components that supply those nerves. So there’s some benefits and some brain protective benefits and brain healing benefits that they’re seeing with early return to cardiovascular exercise. 

That’s not part of the standard care right now. I’m excited to see it phase in phases become more standard practice. But once again starting simple, starting safe, something like a seated stationary bike and managing the expectations, the individuals saying, listen, your symptoms are going to get worse during this. Uh this about let’s just do a little, let’s see where you’re at right now and we can use it to help heal, but we can also use it as a gauge of how you, how you doing over time. I mean, you talk about something like that plus eye movement tracking technology which can show change, you know, and changing course or a few days. I think our return to exercise. Return to performance, Return to training protocols are gonna change pretty significantly in next few years.

Cheng Ruan, MD

Wow, that’s gonna be exciting to see when we’re able to execute a lot of these technologies within these populations. Well, man, what’s what, It’s been a wonderful conversation with you. We can talk all day long, but I think that, yeah, that’s the big takeaway is that, you know, within the military population, there’s so much we can do for, for total body health and brain health, right? And mental health as well, that um, it doesn’t necessarily, you know, have to be um, it doesn’t necessarily have to be a losing battle when it comes to brain health. You know, we have our brain has the amazing ability to heal and we have an amazing ability to look at the brain in ways we’ve never looked at before using technology as well. And I want to thank you for what you do. I mean, you’re doing something that nobody the military talks about just, you know, and uh, and the ability for you to, to get this information from a functional perspective to that population is absolutely extraordinary. I wanna thank you for what you do.

Bryan Stepanenko, MD, MPH

Thank you, Cheng

Cheng Ruan, MD

Thank you.

Bryan Stepanenko, MD, MPH

Gotta say we’re not talking about it yet. And there are definitely pockets and groups that are being trained and seeking out this information, this knowledge and incorporating it immediately, because once you know, it, you can’t unknown it. And once, you know, it, you start incorporating it to save lives and help people and improve quality of life immediately. I know you’re doing that with your population over there in Texas and then with your reach through things like this. I just thank you for the opportunity to share some of the lessons learned and some of the experience here really appreciate you.

Cheng Ruan, MD

Alright, appreciate you. All right, thank you very much.