How To Improve Brain Health For Those With Rheumatologic Conditions

Introduction and Dr. Aly Cohenu2019s Background 0:00

Welcome, Aly. I am so glad that you agreed to be interviewed. The issue of neuro and psych symptoms for patients with rheumatologic disorders is very, very common. So please introduce yourself to the audience. Tell us briefly who you are and then we'll get started. Right. Well, first of all, thank you for having me and for welcome me to your audience. So this is a real pleasure for me to share information as best I can. And so I am Dr. Aly Cohen. I'm a rheumatologist, integrative medicine and environmental medicine physician.

I practice in Princeton, New Jersey, and I teach as much as I can wherever anyone will have me in high schools, colleges, and of course, the smart human, my platform. So it's always lovely to be asked by a colleague to talk real turkey about the immune system and certain nerve neuro immune situations which are very common in rheumatology. Yeah, so let's talk about that. So what are some of the rheumatologic disorders that have these now neurologic and psychiatric symptoms that we call neuro immune symptoms?

Yeah. So, you know, there are many, many autoimmune diseases, as you've talked about in your past. And I'm probably on the summit when it comes to certain rheumatologic conditions, pretty common ones that I see on a regular basis. A few come to mind right off the top of my, my, my brain, which is, you know, lupus, you know, systemic lupus erythematosus is a pretty common autoimmune disease. It has increased in its incidence across the world. And and that has happened over the last several decades.

We are very aware that and patients certainly are aware that there are certain psycho, I should say, neuro immune and what we call, you know, lupus brain or, you know, affects of the brain, whether it's as simple as cognition and memory, foggy brain all the way through to real inflammatory conditions at the source brain, which is, you know, the neurons themselves, ribosomal components which are intracellular. So we know there are certain blood tests that can be tested in order to see if that's actually linked, you know, and can make a diagnosis of lupus based on some of these antibodies that are present in the blood.

So lupus is one of the more common ones, more, you know, diseases that are in my rubric

Rheumatologic Diseases with Neuroimmune Symptoms 2:37

for neuropsychiatric symptoms and vasculitis, which is just inflammation of blood vessels that feed the tissue in our body. You can have vasculitis, some skin, you can have vasculitis of different organs, but certainly can have influenced inflammatory blood vessels in and around the brain. Rheumatoid arthritis and. SHOGREN Certainly, you know, very common autoimmune illnesses that I take care of. And there are a variety of psychiatric components to that. Those conditions, certainly, again, the brain fog and cognition issues, poor memory, often too related to this inflammatory state.

There are coagulopathy which are blood sticky syndromes of the blood that are associated with rheumatologic conditions like lupus. Or it can be primary like Antiphospholipid antibody syndrome, which can pose a risk for stroke and certainly memory and cognition issues. And then there's sarcoidosis as well. So there's a variety of illnesses that may present in joints, but then actually have neuro immune consequences or risk factors to them as well. Again, everyone who's listening this matters to me a lot because my of grandmothers who have rheumatoid arthritis, I have uncles and aunts and cousins with inflammatory bowel disease, rheumatoid arthritis, and I have in-laws that have had issues with systemic lupus.

So I certainly have seen these rheumatologic disorders in my family and I've seen the neurologic and and psychiatric kinds of problems. What are some of the symptoms that you see in your in your practice? Well, so in terms of the lupus patients that I see, I certainly want to make sure that cognition is is intact memory computation. You know, those are the sort of classic, testable ways to see whether or not someone is kind of either brain is working and really connecting on ideas and numbers, time, place, you know, those kind of things.

But then also there's this interesting phenomenon of fatigue or brain fog that really is hard to quantify. I know you do this quite well in your Ms. patients. It's it's little, I would say, less cut and dry. And it's certainly not used on a regular basis for most rheumatologists to really understand fatigue levels. And there's, you know, nice to have the time to be able to add that to clinical exams. But unfortunately, it's not often done. But fatigue is a lot, I would say harder to to quantify.

It's subjective in many ways. And I think that that's one of the things is teasing out what's clinical and visible. And, you know, you can see a swollen joint, but you can't always touch and feel cognition or Teague and quantify that. And I think that's a real challenge for for patients to express as well. And so what are people with these rheumatologic disorders experience? You mentioned fatigue, so they're probably experiencing maybe some brain fog. Are they having difficulty to navigate in, say, social relationships or work relationships.

That can that could be a real part of it, maybe as a consequence to even some of the fatigue as a downstream consequence, because people don't want to necessarily go out, they don't want to socialize, they don't want to connect with with other people. But it could also be things like vision changes, which is certainly part of the you know, the brain structure and the brain function is having visual issues. Certainly there's inflammatory visual issues like optic neuritis that are not just solely related to multiple sclerosis, but very common.

But you can see that in lupus and you can see uveitis or inflammatory eye conditions for psoriatic arthritis, which is very common. And so I think that when you think about when I think about the brain, I think not only how are they functioning, what is their social community relationship situation, what is their computational and memory situation? But also are they having anything like hearing loss, vision loss? And these can be very important considering that some of the mechanisms might be at the actual, you know, brain tissue level.

Okay. Now, you and I come at this from a different point of view than many of our conventional specialty colleagues. And I know one of your areas of passion has to do with the connection between toxin exposure and rheumatologic disease. Can you tell us more about that? Yeah. You know, a lot of my work since becoming a board certified rheumatologist

Common Symptoms: Brain Fog, Fatigue, and Sensory Issues 7:26

and then get awarded in integrative medicine, which really is a deep dove in nutrition and sleep medicine and sleep hygiene and stress management and on and on was really this big connection between environmental chemicals and the immune system. In fact, I'm actually working on a new book on this particular connection because so much of the literature is on the endocrine systems relationship with chemicals and endocrine disruptors. But I think less has been focused on the immune system disruption of these chemicals.

And what's interesting is there are quite a few wells studied, you know, if not many chemicals in industrial, you know, our environment, TCE, the Perfluoroalkyl, BPA, which a lot of your audience probably have heard of, but there are thousands of other chemicals like flame retardants and how they affect our immune system and trigger them into an inflammatory response is very powerful, certainly how it can affect our brains and our gut. So people in our audience. So in the mention of all these chemicals and they're probably thinking like, well, but I'm not exposed to that because I'm not working in a factory.

And, you know, I, I live in a newer home. So is this really an issue? How would people know? Well, it's interesting. It's a it is an issue. I try you know, there's certainly ways to test blood, urine, breast milk. This has been done through our government, through and Heinz data, which is a collection of data every two years by the CDC for many, many years. But then there are third party testing, academic centers. And certainly this the researchers that I work with as well who do large studies in terms of exposure to these everyday chemicals.

And I say every day, because they really do infiltrate our lives from cleaning products to personal care products that are unregulated in the U.S., even to flame retardant chemicals on our couches. You know, there's just a host of chemicals, you know, really profound, even drinking water that have really made their way into our body on a regular basis. And there's there's plenty of things we can do about it. I mean, I don't want to be sort of, you know, a naysayer in terms of, you know, oh, it's too big of a problem to conquer.

That's absolutely not the case. And as you as you are well aware, you know, you thought it was there were many things you couldn't conquer and you did. We can all really think about those things that affect our body, that get into our body, personal care products, what we put on our skin, what we put on our children's skin, what we breathe in our home in terms of air fresheners and, you know, carpet powders and all of these scented products. And we can really cut back on them. And no, and studies have shown that that also reflects in body levels, body burn of these chemicals, which actually is associated with either increased or decreased risk for a variety of diseases, particularly immune system disorders.

Okay. So I think I'm hearing you say take the time to look at my personal care products and my makeup and to get probably or organic or use something like the Environmental Working Group Clean 15 for food, dirty dozen for food. And they have some version of this for personal care products.

Environmental Toxins and Immune Disruption 10:45

I know I'm a big believer in this radical thing known as soap and water. And if you want to put something on your skin, olive oil, if you want to put something under your armpits, a coconut oil, and then just take a shower every day and you don't need all that stuff. And I never really got into makeup, so I didn't have that particular burden yet. And it turns out that there's plenty of great clean makeup companies. I mean, when when we think about getting rid of chemicals, a lot of people are kind of horrified that all their favorite products are going to be thrown out or they're not going to be able to wear the kind of makeup day or clean with the kind of products they like.

But it turns out there is a vast majority. I mean, a vast amount, I should say, of chemical, chemical companies or beauty companies that are working to really lighten up the load of some of these toxic chemicals. And you're correct, Environmental Working Group is a very respected website made up of toxicologists in their team, and they vetted over, I believe, 80,000 personal care products at this point because, you know, even if one ingredient is organic in personal care, you know, these companies have the ability to just say the whole product's organic, even if 99% of it is just, oh, my God.

So it's really important to know that USDA Organic is primarily best used with food in the food system, because that's where as highly vetted and highly the category is quite high. So I say always stick with USDA organic foods whenever possible, particularly frozen foods because they are much cheaper than fresh and even fresh lose. It's a lot of it's nutrient value because it travels in the food system. So so I'm a big fan of transferring, you know, bags in plastic, obviously, into glass or stainless steel from the freezer.

And that USDA organic is really a really important label for people to keep in mind. But cosmetics, you have to vet them out. And the trickier, you know, situation. And cleaning products. Does the Environmental Working Group have vetting of cleaning products? Yes, they do. So they do a very nice job of that. And there's also a company called Clear Air that is another great resource for, you know, looking up products and making sure that they're vetted. So there's there's a lot more competition even in the world of clean beauty and clean cleaning products.

So it's moving in the good direction, even though manufacturing is not being held accountable and the regulations are not required before these chemicals go into our products and make it to the shelves. But then, thankfully, we have companies that are really working hard to get them out and give us vet information. And what are your thoughts about any kind of purification systems? Do you have your rheumatology patients add any of this for their living space at home? So absolutely. I you know, when they come to me, I think they know they're going to get a big dose of something because, you know, I'm all about prevention.

I'm all about cleaning what you have control over in terms of the air quality, your air space, getting rid of chemicals we bring into our home is one of the best and cheapest ways to really reduce that body burden of chemicals into your body, because it gets into dust, which is, you know, gets on pets and their paws gets on children's toys because it's sticky. So if you clean up the products you bring into your home, that's going to reduce that exposure. But also, you know, when you live in certain areas where there may be things like smoke, you know, California areas, you might want to have an air purification system.

But I also think not just of air, you know, you can open windows, get great plants. And I've talked a lot about different, you know, mother in law's town spider plants. Most plants will have some type of detoxification process, but primarily keeping it out of your home. And then, of course, you know, drinking water is one of the biggest beefs I have in terms of keeping chemicals out of your body. Now, everyone is listening. Mother in law's tongue, you know, is that plant green, long spikes, incredibly easy to grow, very tolerant, does not need a lot of light.

And so for those of you who feel like I can't grow plants, I bet you'd be able to do very well with mother in law's tongue. So with all of your patients come in, they get this clean. What you can control. How long would it take for them to see some sort of impact on their neuro immune symptoms? So the idea is that not one thing is an entire slam dunk. What I what I try to give patients a perspective is that there's so many pieces to this puzzle. And then if you tweak and work with each one, even at your own pace, it's not just removing chemicals, although that's a huge help in terms of helping clinically.

The goal is, but you want to manage sleep, you want to make sure your sleep, which is so critical to the immune system, is as good as you can really make it. You want to make sure your drinking water is filtered. Do you want to think about the USDA organic food quality of your food that you eat? But there's also other components of human health and thriving, which is social relationships and community and spiritual, you know, so when you put all of these pieces together is where you have the greatest, you know, hope for for for change.

And I've seen this happen over and over again with my patients, is that when people are really ready to sort of hunker down and do some of these bigger changes, which seem overwhelming at first until they get into it, you really can start to see improvement clinically. And that also goes for medications. Medications have their risks as much as they have benefit and so we work to, you know, make sure we get them down to the lowest dose possible that helps them have a great quality of life. But keep in mind side effects as well and keep them from having infections.

Infections can be incredibly harmful to the immune system and take people from a very steady state to a state of flaring. And so that has a lot to do with nutrition and getting vitamin D levels up to a very, you know, a robust level and maintaining it.

Reducing Chemical Exposure at Home 16:58

You know, I took care of people in the VA system, the Veteran Affairs Traumatic Brain Injury Clinic, Primary Care Clinic. And I was having these same kinds of conversations, and many of the people I saw were disabled living on food stamps. They didn't have a lot of money. So we're teaching them how to do these things while living on food stamps. And they were enormously successful. We talked a lot about gratitude. We talked a lot about prayer and spirituality, going outside, turning off their phone at night and then we talked about improving the food that they're eating and getting rid of eating foods that is wrecking their health.

And so I'm going to be really curious, Alec, what were the top foods? So we know what the stress you know of non-starchy vegetables, a good source of protein. What were the things that you asked people to remove when they were ready to begin removing? So I go with the most important low hanging fruit, in my opinion, based on the research I do, which is drinking water in terms of our body being made up of water, say 85% water. So I really work with them. I understand the costs of filtration and, you know, reverse osmosis versus, you know, a pitcher filter.

They're all worth something. You know, it's you know, we don't need to have perfection. You know, you don't need everyone doesn't need to get an a reverse osmosis. But I work towards getting people in that in that mindset because it turns out that, you know, perhaps reverse osmosis, at least where I know how to get them in, you know, they're not on, you know, terribly expensive anymore for anyone to to find they are more upfront costs, whereas the drop ins for even pitcher filters can add up to a lot.

So, you know, when it comes to costs, it's a matter of how to manage that, whether it's upfront or sort of, you know, you spend over time. But that's one of the biggest conversations I have is why water is is a problem and how to fix that certainly food quality. And then I, you know, I really talk about not only taking away chemicals out, but really adding the nutritious components to food, to whole foods that are organic as much as possible. Because there is a protection mechanism. You know, nutrition does have a way, particularly with the B vitamins.

Omega is there's plenty of studies that show and I write about this a lot that you can actually offset what's called DNA methylation, which is changes to our genetics, our genetic expression, risk by what we eat. So there is a protection mechanism. So it's not just what you take away that sort of off, you know, the sets off the immune system. It's what you also add in is what I consider fruit, you know, human fertilizer, what you add to the body that really protects it as well. And that includes clean drinking water.

So it's really a twofold conversation. And I always meet people where they're at because, you know, you really can't you know, I used to eat Cheez Whiz and Oreos for most of my life. And so, you know, I come from a place where if I can do it, anyone can do it. And and I do understand cost and figuring that into the equation. So water is your it sounds like your biggest area of focus and concern in again, anyone who's listening. I grew up in rural Iowa. We had a private farm. Well, and I've since read and I've learned that in Iowa, 80% of the farm wells are contaminated with atrazine, which is banned in Europe because of its toxic effects.

So I had grown up, you know, drinking atrazine in my water. Is that what do you think? Is that part of why I developed M.S.? Well, I can never you know, obviously, as you know, causation and association are really fine lines. And it's very difficult to prove causation in humans because we have so many confounders. It's much easier in a place where you can kind of control their genetics and you can control their outcomes in their life span much, you know, in a much shorter way. But I will tell you that having grown up in New Jersey and Pennsylvania, add to the to number one and to top Superfund sites in the country.

In terms of the states, California, I believe, is either two or three. You know, our our municipal tap water is affected as well. It's not just, well, water our municipal tap water, which serves 80% of our public you know, of the population of the U.S., 80% actually is only covering 91 chemicals and protecting us from, you know, elevated levels of 91 chemicals. And they've done this only for 50 years. It's not really changed much since the Safe Drinking Water Act in 1974. So, you know, we have a problem not just with Wells because, you know, of course, it very, you know,

Water Filtration, Diet, and Nutritional Support 22:00

absorbent and chemicals can travel miles and miles towards, you know, towards a well, we know that from many, many, you know, stories in the news, Love Canal and Toms River, New Jersey. And, you know, certainly Flint, Michigan is part of the municipal system. But you know, wherever it comes from, I believe we have a we have an ability and, you know, we're quite capable of cleaning it at the tap at the point of use. So wherever it comes up into your home, you can control it with a filtration system at the point of use before it gets into your glass.

So, you know, it gives people a lot of control. And I really do believe we should be giving, you know, reverse osmosis water filters to communities and let people have their dignity of not needing to run and get water bottles that are plastic, have their own issues. I mean, if we just subsidize these systems through government, we we to me, it just seems like a much better solution than always having to Whac-A-Mole, you know, exposure issues with the drinking water around the country on a regular basis.

And and it will likely get a little worse, you know, if not much worse with climate change. So I think we need to think, you know, what is our system for water that we're moving into? Even if you start off with a water pitcher, at least you're starting to get an idea that it matters. And I think that's when you can start moving into maybe a more aggressive way of cleaning water, you know, so people have lives that are, you know, college or new apartments or they're traveling or different jobs and life is fluid.

So I like people to think about wherever they are, how to kind of incorporate some of these things in a way that's reasonable for them. So own your own home. A reverse osmosis may be an option for you if you're renting or you're at college or traveling. I know when I travel, I like taking the filtration system with me, so I have clean water. And rental properties. I you know, if there's an issue with the landlord, I often write a prescription saying this is required. It's they're not big systems.

They're under the kitchen sink and they serve to, you know, for food and drinking water, which is the biggest source of ingestion and exposure. So, you know, I think we need to start thinking in terms of, you know, you can take it with you, you know, $100 for a plumber to take it out and you can take it with you to your next rental. I wouldn't say college as much, but certainly I know kids are getting you know, you know, water pitchers that are highly rated to, you know, to use during college or whatever experience, you know, people are going to.

So, you know, you can be clever and think it through, but they're not really cost limiting anymore as much as people might think. So in your so in my practice, I have more more. Although I do have a rheumatologic and inflammatory bowel disease. When we began working with people on their diet and lifestyle, the first things that people notice and they typically will see this within three months, we reduce fatigue improvement to clarity and better regulation of their moods. What is your experience?

I see that my first visit is usually really high impact and that's that discussion of removal of chemicals and then sort of adding the nutritional tests. I mean the nutrition nutrients like omegas and Vitamin D and a great multi vitamin I usually see that second visit is usually much more improved in terms of symptoms and it's really maybe because they're really incorporating it, they're kind of but also because they're starting to see that their body, you know, how their physiology has been lacking in these nutrients and too much chemicals.

Is that like a six month that people come through twice a year or. I'm curious what I look at. Everything, everything in life. The three month interval, my husband's on a three month lease for 20 years. So, you know, everything is fine because I think a lot of it is in three months. And I think it's also digestible time period where people can wrap their head around it. But I will say to some patients, I think that you are going to have a totally different body in six months, you know, just based on being maybe obese or having or having all of these, you know, classic American chronic illnesses.

I can see from a patient's willingness and interest that they may likely have a very different body habitus and feel great within a six months to maybe nine months period. It's not overnight, but it's certainly I'm inspired by their by their interest. Which I remind people in my practice that our cells or life is a self-correcting biochemistry and we are continually rebuilding ourselves. We are our gut. The lining of my mouth to my anus turns over every ten days. My skin, I think it's once a year.

My brain and spinal cord, seven years, my bones 20 years. So we are continually replacing all of the molecules in our body, molecule by molecule, and the better environment that we make, that future body will keep getting better and better and better. Yeah. I agree with that. That's a wonderful way of sharing with patients that you have an opportunity constantly to keep, you know. Creating the system. Absolutely. If you cut your finger today, three days later and typically heels 100%. We've done that a thousand times since we were born.

So I, I tell patients our bodies have a proclivity to heal evolutionarily. We just have to give it the right, the right setting, the right environment

Timeline for Improvement and Integrative Treatment 27:48

and let the body do what it's trying to do. For the most part. Now, the other thing that I that I've noticed in my clients and that I want you to comment on yours, is people come see me and you know, in that first year, they use it often 10 to 15 years. And they watch people come and say, you know, I saw my kids for the first time in about a year and they didn't recognize me because I looked well, I've lost weight. And they said, I look ten years younger. Are you observing that same kind of euthanizing in your in your clinics as well?

I am. I'd like to say that, you know, for the most part, things go, you know, in a positive direction. And again, that doesn't just include the nutrients and getting rid of chemicals. It's also in my world as a dermatologist, I use medications as well. And, you know, some of them are incredible. I mean, many of them are incredible given that I trained 25 years ago, you only had maybe two drugs for rheumatoid arthritis. Now we have 25. Maybe it's a little overkill, but let's just say it's better to have the options to integrate the right medications if needed with this lifestyle change.

And I do see a fine balance, but a wonderful relationship between those changes and how people's quality of life improves, how they feel more energy, that fatigue goes away. And again, it's getting that balance. And it's also saying to patients, many of whom come to me thinking that all meds are bad because I'm integrative, that I've done this long enough to know that these medicines can be incredibly helpful. So it's just a matter of getting the right balance. And then, you know, that's that's what people do.

They actually tend to feel much better because that right combination. Well, anyway, this has been amazing. So helpful. I'm sure everyone who's listening has found this to be so incredibly useful. I want to thank you so much for being part of this summit. And can you people come see you as a patient? Yes, I am. I'm in Princeton, New Jersey, where I grew up, actually. So I'm here and people could come visit me. But I also do telemedicine for people, you know, quite frankly, around the country and around the world, if it's coordinated.

Right, with my sleep schedule.

Patient Outcomes, Practice Information, and Closing 30:18

But but yes, I am still taking patients and I love my job and I love my patients. So, you know, I think that this is a hopefully that that plays into my patient relationship with them because I think you need coaches, you need supportive physicians like yourself. We need to be, you know, the positive light in difficult situations. I'm happy to see patients that they're interested. Excellent. And what is your website. Aly Cohen MD dot com and the smart human dot com is my I educational work in environmental health.

Great thank you so much. This has been wonderful. My pleasure. Thank you so much.