Aly Cohen, MD, FACR, is triple board certified in rheumatology, internal medicine, and integrative medicine, and a trained expert in environmental health. In 2012, she was honored as the recipient of the Jones/Lovell Rheumatology Scholarship at the Andrew Weil Center for Integrative Medicine in Tucson, Arizona. She has collaborated with the Environmental Working Group, Cancer Schmancer, and other disease prevention organizations, and is coeditor of the textbook, Integrative Environmental Medicine, part of the Oxford University Press/Weil Integrative Medicine, Academic Series. In 2015, she created TheSmartHuman.com to share environmental health, disease prevention, and wellness information with the public. She lectures nationally on environmental health topics for elementary/high schools, colleges/universities, medical schools, and physician training programs, and is a regular expert guest for television, print, and podcasts. She has been the recipient of numerous awards, including Top Docs NJ in rheumatology from 2016 to 2021, the NJ Healthcare Heroes Award in Education for The Smart Human educational platform in 2015, and the 2016 Burton L. Eichler Award for humanitarianism. Dr. Cohen is working to educate and empower the next generation to make safer, smarter lifestyle choices through the creation of environmental health and prevention curricula for schools nationally. Her TEDx talk, “How to Protect Your Kids from Toxic Chemicals,” can be found on YouTube, and her health and wellness tips and recommendations can be followed on Facebook at The Smart Human, Twitter, and Instagram: @thesmarthuman. Also available are The Smart Human newsletter, her latest posts at TheSmartHuman.com, and her podcast The Smart Human. Dr. Cohen is also the co-author of the recent, bestselling, consumer guidebook, Non-Toxic: Guide to Living Healthy in a Chemical World, published by Oxford University Press, and part of the Dr. Weil Healthy Living Guides.
Robert Rountree: Why don't we start by telling our readers who you are and what you do? Please tell us about your clinical practice—what kind of patients you see, etc.—and then after that I'd like to get into how you got there.
Aly Cohen: Well, I began my training as a conventional Western rheumatologist trained in internal medicine at Beth Israel, New York, and went to Montefiore, The Bronx, and Albert Einstein. These are really excellent institutions for training in Western medicine, for rheumatology, and I really just loved it, loved the immune system, loved its intricacies. I was challenged by it. It was not easy, but I loved what I was seeing, especially in New York City, where you see just about everything.
Rheumatology has expanded exponentially. It really used to be just joint pain, basic joint-related issues from osteoarthritis, mostly rheumatoid, some lupus, and some autoimmune diseases, but now—and this will play into where we're going in the future—even tick-borne illnesses have expanded. Mosquito-borne illnesses have expanded. And with climate change and global warming, there's going to be added burden to the rheumatology world, perhaps more than some other fields in some regards—and we'll get into this later—because the world is changing, and because there aren't seasons anymore for certain previously “seasonal illnesses” such as Lyme disease. There are a lot of future issues going on in the world of rheumatology that are going to be scary because there's going to be a greater need—people are aging and living longer, but they're living sicker. And because so many illnesses present clinically with joint pain, and joint pain covers almost everything you can think of in rheumatology—from crystal arthropathy, like gout, to bacterial, viral, and mold infections, to autoimmune disease, to gluten and other food sensitivities—it's going to be a challenge for rheumatologists as we move into the future.
Dr. Rountree: So even your mainstream colleagues would say the purview of what we're doing in medicine is really expanding.
Dr. Cohen: I think you're right. Environmental health awareness and education is going to become a major need in medicine. A pulmonologist, for instance will likely see an increase in illnesses associated with worsening air quality. Predictable presentations such as allergies will likely move into an area where water pollution, air pollution, and even household cleaner ingredients will have to be added to the differential diagnosis, and not just assume ragweed is the culprit. This out-of-the-box thinking will be necessary by all fields of medicine.
People often ask how I got into the field of environmental health or integrative medicine. I really got into this by the conventional route because I didn't know better. I went through my training and was very health-conscious in terms of exercise, but never connected health with food and my diet. Twenty years ago, when I was dating my now husband, also a physician, who was really into health and wellness, I started to pay attention. And it was he who stumbled upon the integrative medicine fellowship at the Arizona Center for Integrative Medicine, now called the Andrew Weil center for Integrative Medicine. I also began eating more thoughtfully, more healthfully. At this time, I had young kids. I had a dog that was sick with autoimmune hepatitis, which is unheard of among dogs and especially Golden Retrievers. I was so heartbroken, and I couldn't figure out why he was sick, and I looked at his food and his drinking water, and I was thinking about the plastic toy he always had in his mouth, and I was thinking about pesticides, because we live on a farm in New Jersey. And I'm thinking that could be affecting his immune system, and I'm realizing how little regulation there is for humans. And this is all while I'm still going through my training program with Dr. Andrew Weil (Fellowship in Integrative Medicine, University of Arizona School of Medicine; https://integrativemedicine.arizona.edu/education/fellowship/), and they have a whole environmental health section at that time that was in the curriculum. So, all these worlds were colliding—rheumatology, integrative medicine, and environmental health—and it really changed how I perceive and practice medicine.
Dr. Rountree: All these doors started opening for you.
Dr. Cohen: Yes. I didn't know that I was doing it for any reason, and when Victoria Maizes and Andy Weil got hold of the idea that I started reaching out to Environmental Working Group (EWG) and creating a CME for doctors around the country doing grand rounds—I think I did 25 of them—they heard that I was doing this, and they said, “Well, why don't you work with us and kind of be the liaison?” And I was like, “Absolutely.” And then I said to Victoria, “Oxford and Andy publish this amazing series of academic books, but they don't have ‘integrative environmental medicine.’ Let me write it.” Then essentially Andy gave me the green light to write Integrative Environmental Medicine, which is the 13th book in his academic series with Oxford.
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Andy required me to bring on a seasoned researcher, and thus began my search for a partner. I contacted Fred vom Saal, PhD, Professor Emeritus of Biological Sciences at the University of Missouri, Columbia, MI, and wouldn't you know it, in the first conversation, he said, “Yes, send me over your table of contents and your idea.” He's a remarkable person and has become my friend and mentor. We co-edited that text and then went on to write the consumer version published in 2020, Non-Toxic: Guide to Living Healthy in a Chemical World, also published by Oxford.
Dr. Rountree: Dr. vom Saal has done a lot of work on the endocrine disrupting effects of chemicals like bisphenol A and the whole notion of low-dose exposures sometimes being worse than high-dose exposures? I believe the effects are nonmonotonic?
Dr. Cohen: Yes, him and his colleagues.
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Low-dose exposure to many chemicals can cause endocrine disruption. Nonmonotonic instead of a classic linear dose-response curve.
Dr. Rountree: Conventional toxicologists are all about the linear effects of toxicants: “the dose makes the poison.” Once your exposure goes below a certain threshold, you're fine—no adverse effects expected.
Dr. Cohen: Correct.
Dr. Rountree: Tell us about why that kind of thinking is a problem.
Dr. Cohen: Well, most of us, in real life, think that that would make sense, right? For example, the more we drink alcohol, the more we get intoxicated and maybe don't feel so well. The more you eat cake, the more your belly's going to hurt. The more you're around a toxic chemical like benzene, the more likely you're going to have a risk for cancer. However, what he and his colleagues found out was that—and actually haphazardly, through some botched experiments that they couldn't understand why the results came out so weird—it turns out that there were plastics leaking from the animal water bottles, in short. What they discovered is that low-dose—like extremely low-dose, parts per million, parts per billion, parts per trillion—could elicit the same dramatic reaction experimentally as the high-dose exposures, when exposed to the same compound. And that just threw the conventional logic on its head, because the common-sense thought—and I would have thought this, too—is that the more you are exposed to something, good or bad, the more you're going to experience a reaction to that exposure. And they found this with Bisphenol A initially, that was one of the first endocrine disruptors, and the reason it's called an endocrine disruptor is because hormones are quite active at low doses—parts per million, parts per billion, parts per trillion, in the human body; their energy is conserved over evolution, so just a little bit of hormone released in the body is capable of dramatic, exponential effects on the human body—similar to endocrine disrupting chemicals (EDCs).
Dr. Rountree: Endocrinologists measure hormones in levels of parts per billion all the time. So, they probably didn't need a lot of convincing?
Dr. Cohen: Well, the Endocrine Society wasn't quick to jump on this information, because, again, these are chemicals. They're not familiar with chemicals. Doctors aren't toxicologists. They know their area; they know their hormones. But—and I found this out myself—many doctors are not so keen learning new information after their training years. It's just uncomfortable.
It's crazy, but it's true, that if you don't learn something during your training years, you feel that it wasn't validated. So that's a whole other area of disappointment that I'm working with, and working on with educating colleagues. But the idea was that this discovery of EDCs was really earth-shattering, and as the literature grew, and the types of chemicals tested to see if they had the same nonmonotonic response, and experiments were replicated worldwide, and the data just began to grow—this has now become a part of conventional scientific wisdom now. It's important to note that you have to have the assays and technology to look at chemicals at such minute quantities, like parts per million, parts per trillion, and of course manufacturing companies are not held to or required to do any safety or toxicity testing for what they create in the U.S. Sadly, it's a remarkably unregulated world we're living in here in the United States.
Dr. Rountree: The endocrinologists have now started talking about this problem in terms of its impact on precocious puberty, low sperm counts, and all kinds of hormone-related issues. You're saying that rheumatologists need to be paying attention to this as well?
Dr. Cohen: Well, I will tell you as a rheumatologist for over 20 years, the field of rheumatology is now experiencing an exponential growth in autoimmune disease cases. Although rheumatologists are perhaps the most well-studied, well-versed, and well-trained in the field of Western conventional autoimmunity and how it is treated through Western therapies, what's going on in autoimmunity is shocking. I'm seeing more people getting autoimmune diseases at younger ages and without any family history. This can't be from better diagnosing skills, it's from the enormous explosion of untested, synthetic chemicals that fill our modern lives that manipulate our endocrine and immune systems. I feel like I'm living it on the front lines, on the battlefield, and seeing this all play out in real time.
Dr. Rountree: Is it generally accepted by the academic medical community that there's a true increase in these diseases? Or is this more something that clinicians are seeing in their practices and wondering when the ivory tower folks would catch up to reality?
Dr. Cohen: The epidemiology is there. In fact, I'm working on a new book specifically on this topic, and the absolute epidemiology of increase in the incidence and prevalence of autoimmune diseases across the board—including type 1 diabetes, and that's including rheumatoid arthritis (RA)—are absolutely growing.
Dr. Rountree: There's no question about it.
Dr. Cohen: No question about it. I will hang my hat on it. The idea is that these numbers are growing, it's in all the major medical journals, all Western peer-reviewed journals. It's just understanding that there is something huge going on here. We are not getting better at diagnosing. As Western doctors, we are mostly just catching the symptoms and somehow getting them to a diagnosis—they're not necessarily better at diagnosis, especially with the 15–30-minute appointments that are now standard of care. The other thing is that most patients are really getting autoimmune diseases with no family history. This is not something where the genes are changing. To have genetic changes in clinical disease over the course of one or two generations is very, very quick, and that's not just a random gene mutation—that's an environmental cause.
Dr. Rountree: I've got to make a comment, which is that I repeatedly see journal review articles regarding an autoimmune condition that say “the etiology is unknown, but it appears to be some combination of genetic and environmental factors.” What does that mean exactly? The authors never say what specific environmental factors are involved and what specific pathways can initiate dysfunction and disease. You are telling me that we already know what a lot of them are.
Dr. Cohen: Yes, exactly. Well, this is why a book on autoimmunity and environment needs to be written. And I'm working on it. We know which environmental factors cause specific illness. But everyone's afraid to say the wrong thing without enormous, double blinded studies behind them. And I just retracted “causation” and changed it to “association,” because I'm afraid that you can't make a one-to-one connection between cause and effect, which is true. You know? Genes play a role. Lifestyle plays a role. And then there's also environmental exposures. But the only one-to-one direct connections are smoking and lung cancer, and skin cancer and sun exposure. You can pretty much draw a one-to-one line of causation to those two illnesses.
Dr. Rountree: What about the increased risk of RA in cigarette smokers? Is that just an association?
Dr. Cohen: Yes. I would say that's an association, because then all smokers would have RA, which is not true. It's taken a lot of years to feel confident giving a thorough environmental health evaluation to my patients, to tease out lifestyle, genetic, and environmental contributors to disease. I don't think I could have said this 5 years ago, or 10 years ago. I have 20 years of rheumatology practice under my belt now—I think I have a lot to say about environmental associations with autoimmune disease.
Dr. Rountree: You have a lot to say about the evidence. And it sounds like you've done enough digging into the research that you can say what you say with confidence.
Dr. Cohen: Yes. And you know, the thing is, it's a matter of just collating the information, I think. I teach medical students and high school students and even my patients how to look up PubMed articles. We all have access to the same peer-reviewed journals. And if it doesn't have a lot of evidence behind it, I usually don't like talking about it.
Dr. Rountree: Is this information starting to make its way into the textbooks of rheumatology or any mainstream review articles in rheumatology journals?
Dr. Cohen: Well, it's interesting. Studies show that low vitamin D affects over 400 immune system pathways.
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There are a million articles discussing how vitamin D is beneficial for lupus prevention and management.
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I have yet to have a rheumatologist test vitamin D routinely in patients, especially autoimmune disease patients, and then do something about it. They were never trained in nutrition in medical school, nor was I. So there's sort of a disconnect between what we read and what we do. Maybe that's because we have 15-minute appointments. Most conventional rheumatologists do take insurance, right? So they have an enormous number of patients, it takes 3 months to get in to see a rheumatologist, they're all retiring, and there's not enough fellowship positions for them. They have 15 minutes to cover a lot of material, so they don't have the time. I think that extensive nutrition training, as well as environmental health needs to begin in medical school.
Dr. Rountree: Meanwhile, they're bombarded with ads for the latest biologic. We've gone from just focusing on inhibitors of tumor necrosis factor (TNF)-α to, oh, now it's interleukin (IL)-1 that's the problem. Then again it's IL-17 we should inhibit. Wait—now it's IL-23! So it's all become a Cytokine-of-the-Month Club.
Dr. Cohen: Right! And listen, I'm the first one to say that I'm glad they all exist, because I do use them, and I do think they improve lives in many patients. But the question is: Do they need to be used reflexively? Do they need to be used first? Part of what I do is triage. I'm seeing a patient and I'm seeing how acutely ill they are, to see how I can make a dent then without letting them get hurt. If it's a lupus patient, you don't sit around and do kumbaya and fish oil and vitamin D if they have lupus nephritis active. You have to triage to assess the severity of the illness and then make recommendations for lifestyle, medications, and even evidence-based supplements that may take time to work. Also understanding what the patient is willing to do in terms of the hard work—it's not easy.
Dr. Rountree: Treating symptoms is not such a bad thing, as long as that is your starting point rather than your end point.
Dr. Cohen: Absolutely. And I look at it as a bridge. If I need to put patients on steroids and a biologic to get their symptoms quieted down, reduce pain, and allow them to make decisions, then so be it. If a medication helps the patient to be pain-free to allow them to choose a healthier diet, they can sleep through the night, and they don't feel stressed, and their blood pressure isn't sky-high from chronic pain and swelling, then medications may be a beneficial means to an end. I also work on lowering their medication dose, if coming off the medication is not possible. So there's all different places you can meet a patient. And my job, as I see it, is to sort of triage where they are in their whole disease process, from prevention to diagnosis and management, and just make sure they don't get hurt.
Dr. Rountree: As far as toxins go, are you driven to try and identify the toxin or toxicant that triggered that person's disease? Or are you more likely to go ahead and assume the person with an autoimmune disease has a higher toxic load, that needs to be lowered to restore health? In other words, are you doing extensive diagnostic testing for specific chemicals that might be involved or are you tackling this issue in a general way without having to identify the culprit or culprits?
Dr. Cohen: The answer is B, because as you and I both know, there are over 95,000 chemicals commercially available in all of our products from feminine care products to cleaning products to home furnishings to home textile chemicals, air fresheners to air pollution to water contaminants, so there are just too many to say, “aha! that's the one that did it.” But we have to think about: How do we cut back, in all of these areas of exposure to the human body, what people breathe, what people drink, and what people eat? We can cut back in those two huge body burden loads—it's not complicated, and it's not costly, as far as I discovered. And I thought if you could make it not costly and not complicated, people would be much more interested in taking on those changes. So you have to remove these irritants, and then you want to add in the nutrients that we are all deficient in. To me that is really just the best combination.
Dr. Rountree: Can we talk a little bit more detail about what you do to “detoxify” people? Do you even believe in the term “detox”? Do you do specific interventions, like heavy metal chelation or is your approach better described as “clean up your life?” What's your perspective?
Dr. Cohen: That's a great question. I don't love the word “detox,” I think it's overused, because it implies, similar to a diet, that it's short-lived. I think semantics matter. I believe in lifestyle that matches our evolutionary template. I believe in anthropology, I believe in evolution, and I literally pour it into my practice in my care of patients, because if patients don't understand how we got here, why we got here, and why our modern-day exposures are a problem, they're not going to buy into what changes need to happen. That's kind of critical, so I start with low-hanging fruit. I make sure we have a conversation on my favorite topic, because it has risen to the top as the most important topic, to me, which is drinking water. It's part of my conversation with every patient. And because by volume we consume the most water of all other substances daily, our body needs clean drinking water. I really get into the regulatory failures of drinking water, the importance of clean water, even if you're exercising; you defeat the practice of detoxing through exercise by putting crappy water back into your body. Or you go to the gym, and the gym shower has free shampoo, conditioner, and body wash to use after your workout to sweat out toxins—that's just adding the junk back into your body. So the ironies run deep. I just wanted people to see the same stuff that I see.
I'm often talking to people who have never even heard about the effect of healthy foods on our health. They have no concern about vegetables; they have no understanding of safe drinking water; they have no inkling that any ingredients in their cosmetics are a problem. I'm looking to educate high schoolers and college-aged people. People with no medical background, no scientific background—that's who I'm trying to reach with my work on The Smart Human platform (https://thesmarthuman.com). That's who my books are aimed at. It's for that level of understanding. And these are very intelligent people, but like me in the past, they think that our government is regulating this stuff, and that makeup might be less toxic because it's more expensive, which couldn't be further from the truth. I've found that education level and socioeconomic background do not correspond with healthy choices all the time. So the low-hanging fruit is really: How can I make a dent in removing stuff? Because that's the cheapest, easiest way to just make a dent. It's removing the stuff we purposefully bring into our lives that just fill our bodies, our children's bodies, our pets' bodies, and it's really done passively. It's air fresheners. It's carpet powders. It's laundry detergents. It's flame-retardant chemicals on our couches. It's candles. It's synthetic room fragrance, like sprays and plug-ins. It's all the stuff we think we need, because marketing tells us so. It's lawn care chemicals, because we're taught that we have to have the most pristine lawn in the neighborhood. And it's really just reframing what is good for the human body, and how can we get closer to that evolutionary ideal.
Dr. Rountree: I'm hearing your major take-home message is that exposure to potentially toxic chemicals could be disrupting our immune and endocrine function to an extent that is vastly greater than the majority of people realize. There are huge opportunities for ongoing exposure. Just drinking a green smoothie every day is not going to have an impact if you don't clean up the whole environmental issue in your life.
Dr. Cohen: Absolutely. We are basically really unconsciously doing this to ourselves, in many ways. By no fault of our own. And your green smoothie might be more toxic than you believe it to be. And if you are trying to eat healthy with a kale spinach salad—and conventional kale is listed as one of the most pesticide-laden produce according to EWG—you've now modestly defeated the purpose of your good work.
Dr. Rountree: Absolutely. What kind of response do you get from clients when you start talking about these issues? What kind of pushback or resistance do you get? Secondly, what kind of impact do these lifestyle changes make with regards to how clients respond to your treatment regimens? Are people doing better overall when they make the changes you recommend?
Dr. Cohen: Having been doing this a while, I would have to say yes. Even if symptoms reduce, frequency of episodes, like joint pain flares, get fewer or less intense as with migraine sufferers, energy improves, or gastrointestinal symptoms resolve—there is no doubt that clean food and drinking water make a positive difference in our health.
Dr. Rountree: How does your practice set-up impact your care of patients, especially complicated cases?
Dr. Cohen: What I see mostly is people frustrated with the medical system. They're desperate for either answers or improvement in their symptoms, they're not necessarily interested in taking pharmaceuticals as their only choice, and they're coming to my practice willingly. And I say this because, having been in conventional insurance-based Western medicine, it's very different. People want to be at my office, and they want to learn. A lot of times my patients are wide-eyed and have arms open. I've found that people want answers about their illness, and many feel desperate. Some patients are just interested in the integrative philosophy of not putting pharmaceuticals first. So I have been a very happy physician since incorporating this integrative process. From a financial standpoint I feel fair about the time spent with patients and the amount of money that I charge for my services. As a rheumatologist who sees many chronic cases that require ongoing care, I do worry about my patients' finances, and their expenses can add up. I'm very conscious of that.
Dr. Rountree: You have no regrets from leaving “the system.”
Dr. Cohen: No regrets. Instead of clicking boxes to get paid by insurance companies and Medicare for extra hours each day, I now have the time to serve my patients and educate a much wider audience through my social media platform, The Smart Human. So I'm serving the right people, the way I see it. And I'm doing it fairly.
Dr. Rountree: Definitely. Are you able to talk to your rheumatology colleagues and say, hey, there's a better way—or a different way—of doing things that might be more rewarding? Has there been any interest from members of your clan?
Dr. Cohen: That's a great question. There are very few physicians trained and board certified in integrative medicine as well as rheumatology. And a few years ago, I was invited by another integrative rheumatologist who said, “Let's go to the ACR (American College of Rheumatology) national meeting and let's give a talk on integrative medicine for rheumatologists.” I said, “Sure, let's do it!” Well, it turns out the American College of Rheumatology (ACR) administrators scheduled our 1-hour talk for the very last hour—mind you, there are like 60,000 people from around the world that come to ACR, and they scheduled the talk, apparently, for the last hour of the entire meeting, when everyone was flying home. So if that's not an indication…
Dr. Rountree: It was designed to fail.
Dr. Cohen: Yes, it was kind of designed to fail. Maybe not intentionally, but certainly not set up to reach more people and give this information more of an audience. It doesn't surprise me given that I've spoken to a lot of different departments, not specifically rheumatology but internal medicine, neonatology, pediatrics, family medicine, lots of them, and really there's not that much interest in people making real impactful change to their process or even swapping out chemicals in their neonatal intensive care units (NICUs). After I lecture on endocrine disruptors such as di-(2-ethylhexyl) phthalate in respiratory equipment of NICUs, you'd think physicians would come up to me afterwards to figure it out. I'm happy to share how physicians can swap out bad plastics with healthier ones—it can be done for free through Health Care Without Harm (https://noharm.org). So the response has not been overwhelming, which is why I've pivoted, which I talk about in my TED Talk. I've pivoted to go right towards high school and college students. That was the basis of my TED Talk, How to Protect Your Kids from Toxic Chemicals.
Dr. Rountree: That's great. How did you get to talk to high school and college students? How did you arrange it?
Dr. Cohen: I ran two pilot projects in Princeton, NJ, which is where I practice. I'm friendly with several of the high school principals. And at the time—this was in 2014—I just asked the head of science at Princeton High School, which is a very large public school, and I said, “Listen, would you let me do a pilot project where I'd teach 10 classes, you pick the classes, one-hour lecture on environmental health? And I'm going to do pre- and post-testing on their knowledge base, and then post what they learned and then what their interest is.” So I did that pilot project, which was a big success. I actually couldn't believe it. They were interested. They wanted to know this material. They paid attention. Then I did another pilot project in 2016 where I did six lectures. These were the “don't” topics: personal care products was its own 1-hour lecture; drinking water was another lecture; pesticides and other chemicals and flame retardants was another one; food quality was another one. So I did six lectures. I did pre- and post-testing quizzes. And that was a big success. And so those two pilots served as the basis for my data that I presented at the Gordon Research Conference in Switzerland, and then I turned it into a TED Talk. I vowed that the rest of my life, I'm going to be working to teach young people, high school students about environmental health and how to keep their bodies healthy. These young people absolutely want this information; they're tech-savvy, they want to know what they put on their bodies, they may even choose to have kids of their own one day, so they can help to prevent autism and in utero exposures. Today, just so you know, the American Medical Association talked about the highest rates of autism ever. Right now, the data just came out: 1 in 44 eight-year-old children are diagnosed.
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Dr. Rountree: This high rate of autism is not just from better detection or expanded diagnostic criteria, as some have claimed?
Dr. Cohen: No. Again, just like autoimmune diseases, we now have increased rates of hormone-sensitive cancers. We have the highest rates of autism. New Jersey, my state, has some of the highest rates of autism in the country. Because—by the way, I'm not saying causation, but association—New Jersey also has the highest number of toxic Superfund and brown field sites in the country. New Jersey is among the states with the highest incidence of breast cancer. So whatever that may be, we have to look under the hood here a little bit better. So if we're not going to be able to really push this curricula into medical schools—and I've talked to deans where they say they're just teaching to the board exams—the truth is, kids, high school students really want this environmental health and disease prevention information.
Dr. Rountree: It's a vicious cycle, actually. The med students have to get ready for their board exams, so who has time for anything extra.
Dr. Cohen: Yes. They don't want any extra information. I've offered free curriculum in environmental health. I've offered free curriculum in nutrition that I've written. They don't want it. They say they're covered. So again, you go where the love is, is my favorite expression. And the love is high school. High school students, college students, they love this stuff, and they want really practical, evidence-based information, and that's the goal.
Dr. Rountree: How different that must be for you and your practice from being in the ICU with someone that's got an acute health crisis like lupus nephritis because their autoimmune disease has gotten out of control.
Dr. Cohen: Yes. I lost a patient to severe lupus several years back, who was in her 20s. I inherited her in the hospital after she was admitted for an acute stroke due to anti-phospholipid syndrome. When you see young people dying of diseases that we never really had decades ago, in no way near the numbers we see now, with no family history, it has to make people think: What are we doing to ourselves? And once you see a patient like that, it just makes me even more focused on the prevention world, as opposed to the treatment world, as much as possible. Like I said, I would never pooh-pooh the medications, because they save lives, no doubt. Therapies have become so much more available and have really impacted human health for the better in most cases. Drugs, pharmaceuticals are great when used acutely, if they're needed, but most are not meant to be on as a daily regimen, months or years beyond their intended use. That's where lifestyle and environmental health as a preventative measure is key, so we don't become sick.
Dr. Rountree: Here's a kind of logical extension of this question. Is it your belief that autoimmune diseases are potentially reversible? That's a setup question for something else I want to ask. But first I just want to know your thoughts on that possibility. Because conventional rheumatologists say once you've got an autoimmune disease, you've got it for life.
Dr. Cohen: Well, I would say there are caveats to cure. Cure is like the word diet. Semantics matter. I would say that similar to the concept of remission for cancers, I like to use for autoimmune diseases for the mere fact that we cannot predict that things are going to remain stable, disease free or come back. You know? Life is fluid, right? If autoimmune diseases are affected by stress, I don't know anyone who's going to get away from stress and symptoms are not going to come back. I don't know if everyone's diet is going to stay spot-on for their whole lives. Everything about life and life situations—where you live, your access to organics or clean vegetables or vegetables at all, your access to clean drinking water or a filter situation—all change during the course of a lifetime. Like college kids that I take care of, they want to know what to do for clean drinking water for the next 4 years. Pitcher? Reverse osmosis (RO) in a dorm room? That varies by their living situation. So the idea that things are cured is a little less appealing to me, as opposed to sort of remission, where you can shove symptoms back into a quiet zone by doing as much as you can, even medicinally, or lifestyle or situation, but some things are out of your control—air quality, water quality, access to foods, sleep issues, pregnancy, divorce, moving. All of these things throw a chink into the armor, in which case it's not to blame the patient for coming out of remission, it's just life. And to me, that shouldn't be put on the patient.
Dr. Rountree: OK, let me ask you this: have you seen people who had autoimmune disease that was bad enough to require biologics, but they are now completely off medication?
Dr. Cohen: Yes, sure. Off biologics after being on them? Absolutely. I certainly have patients that have done extremely well. And it's not just getting off of the medication that's considered sort of a success, which most of us would think. It's just as good to lower your methotrexate dose. It's just as good to go on remission, technically, and go off the biologics for 3 to 6 months, or a year. To me, I don't make big expectations as if you've failed if you must go back onto a biologic or another medication. I look at it as just another phase. And let's keep doing better and choose better and work at it. But certainly, I've had patients that even just through diet and lifestyle have really made inroads with their disease. Of course, people can feel well and yet have some underlying issues to follow, such as those with RA patients. If they have clinical changes of their joints as well as changes on X-rays that show that their disease is progressing, that's another level of concern, because they need to maintain their function, not just have pain control. Function is regularly overlooked in medicine, I believe.
Dr. Rountree: I'm thinking about a patient I recently saw with Crohn's disease, who consulted a gastroenterologist that told her, “You need to get on a biologic right now, and you will be on it the rest of your life.” He said that at the onset of her diagnosis. What do you think of that?
Dr. Cohen: I'm often frustrated by what medical colleagues tell patients: “Diet really won't make a difference,” “Supplements just means you'll have expensive urine,” “You'll never be able to have kids with lupus.” I have patients that come into my office crying because their antinuclear antibody (ANA) screening test ordered by their primary was 1:140 titer, which you and I both know is normal in most cases, and yet they're in my office thinking that they're going to die of lupus. Their doctor ordered it, but didn't understand how the test is interpreted, and then gave the patient a diagnosis without a real understanding of the disease. So I've kind of seen it all, and my goal, to be honest, is never to throw my colleagues under the bus. I assume we are all just trying to help the patients we care for, no matter what experience we've had in training.
Dr. Rountree: Right. They're doing the best they can.
Dr. Cohen: They're doing the best they can. I blame the system. And I'm very vocal about it, actually. I blame medical schools. I go after deans and try to get them to make a difference in this area. But they're limited, too. What I think has been successful in my location, Princeton, NJ, which has tons of very smart conventional doctors, is to treat patients really well, work to make them healthier, and the patients will advertise their success to their other doctors. I truly believe that is how my integrative medicine work has become highly respected in my community—do right by those patients in a logical evidence-based way, and show the community that this approach is effective, safe, and logical.
Dr. Rountree: Exactly. You're a specialist within a realm of specialists.
Dr. Cohen: Yes! I think it takes a lot of time to learn this stuff, that's all. I don't think anyone who wants to learn this material and be an advocate for both worlds can't do it. I just think you have to want to do it. You have to want to spend the time and money outside of conventional medical training to learn about nutrition, learn how vitamins actually work, understand what chemicals, poor sleep, and stress do to the human body. I have never regretted putting in the time or money for this kind of training or the tools I've been taught to fix these problems.
Dr. Rountree: And you have to be committed to it. As you said, there's only a small handful of integrative rheumatologists around the country. What are patients supposed to do if they go to a rheumatologist who says, “You've got to be on this drug the rest of your life,” and there's no question about it, no discussion? And diet has nothing to do with it?
Dr. Cohen: Yes. So you and I both feel that it's a shame, because the patients are left with no choices as far as they know. And then that's where the Internet takes over. And I think when people are looking for answers, that's where they start, hopefully, to find good information, not so much crazy information. But yes, it's really kind of sad. I've had patients, rheumatology patients from other doctors, other rheumatologists who had told patients not to come back, if they choose not to go on the medicine they recommend. Rheumatologists who literally shut the door on them. And the way I see it is I'd rather work with a patient and meet them where they're at, and build trust, and let them know I'm not going to let them get hurt, and that we'll go at the pace that they feel comfortable. Pretty soon they're doing great no matter whether it's medicines or not, because they've actually built a relationship with a practitioner who's taking care of them and really listening. To me, that's critical. And look, some patients are not doing what I'd like them to do, from a Western standpoint. Some patients really should be on biologics because diet, toxin removal, evidence-based supplements etc. have not been effective. I'm very vocal about integrating medications in because of their added benefit when appropriate. But do I get rid of them from my practice if they choose not to go that route? No. I'd rather work with them than to let them get lost in the system or take matters into their own hands and get hurt.
Dr. Rountree: Let them decide.
Dr. Cohen: Exactly. Just help them decide. Share important, evidence-based information. Build trust and then work together to make a decision.
Dr. Rountree: Are there any nutrients or botanicals that you think have a lot of promise for preventing or treating rheumatologic disease that are being unfairly ignored by the mainstream? You've mentioned vitamin D and I know there are studies on omega-3 fatty acids showing that they lower inflammation. Is there anything else out there that you find really intriguing that you really wish someone would study, that deserve to be investigated?
Dr. Cohen: Yes. Well, I would say to that, to begin with, I believe every human being is “undernutrified,” that we don't have enough nutrient value of anything we're eating, even if it's organic. So in modern-day life there's a deficit in our nutrition, for a variety of reasons and a variety of issues. We're missing basic nutrition and micronutrients on a daily basis, at the right quantities as compared to our prehistoric ancestors. That's key to human health, no matter what you look at. So I believe supplements are necessary to add into most diets because we just aren't getting enough of what we need for the human body to run efficiently. Omega-3 is just one of several I recommend, but Bob, we both understand, right, that 99.9% of fish oil products out there are total junk. So quality matters. Concentrations of nutrients on a label matter. Third party testing for purity, quality, and quantity matter.
Dr. Rountree: Yes. It's oxidized, or contaminated with heavy metals…
Dr. Cohen: Yes, if fish oil is oxidized, or it's not concentrated with enough docosahexaenoic acid and eicosapentaenoic acid (EPA) fatty acids to have any real clinical value it becomes worthless. So you'd have to take 10 fish oil gel caps to get the level that's studied in peer-reviewed medical journals for the anti-inflammatory effects of fish oil. Also, the manufacturer may not routinely test for contaminants like polychlorinated biphenyls or microplastics or mercury. So I teach patients how to read a label. I teach them how to choose a good quality supplement. I do not sell brands. I don't promote anything. I just want people to actually walk into any store and be able to pick up a fish oil off the shelf and know how to understand if it's total junk or not, because that will totally make a dent into whether or not their symptoms improve. I want people to also think about multivitamins. I want people to think about great quality turmeric with black pepper, because of the hundreds of peer-reviewed medical journals that show its anti-inflammatory effects. There are many to discuss and use with patients, but these are some of my basic recommendations.
Dr. Rountree: It sounds like a monograph: The Basic Nutrients Every Rheumatologist Should Know! That should be the standard of care.
Dr. Cohen: Absolutely. I think you're right. Standard of care in modern day life, where food is very inconsistent in terms of quality, consistency, busy-ness. We just don't have a diet anthropologically that was consistent and rich, nutrient-rich, and available. And so because of that, we have to think about, well, how are we going to get these into the human body so that our bodies not only prevent illness of any kind, but also quiet active diseases down?
Dr. Rountree: I get the impression that you don't often find the need to engage in really elaborate nutritional interventions. It's more about, “Clean up your act and bring your nutrients up to a normal level”?
Dr. Cohen: Yes. And then I do have patients, once they get there, we keep moving through our supplements and our different ideas. Ideas like coenzyme Q10. Right? And then it expands. But again, to me, it's like meeting them where they're at, and then getting them tucked in, and layering upon layering upon layering. Otherwise, it's too much, it's just too overwhelming for the average person. I don't like to load them up on supplements without really confronting food, drinking water, sleep, stress management, and exercise discussion. But appropriate supplements, that are specific to that person's health issues is what I go for.
Dr. Rountree: Do you think that most people need a water filter regardless of where they are located?
Dr. Cohen: Yes. Everyone should be filtering their water. There's not one human in the United States that should not be filtering their drinking water. Period.
Dr. Rountree: Because most city, most public water supplies just don't cut it?
Dr. Cohen: Correct. They follow the Safe Drinking Water Act of 1974, with some amendments since then, but essentially under this law, only 91 chemicals are actually monitored and remediated for elevated levels. No doubt, you could argue that the levels the EPA sets for many harmful contaminants are still too high, but that's a whole other discussion. And well water has its own issues. I'll be giving an in-depth lecture on drinking water at Integrative Healthcare Symposium (NYC, February 2022, www.ihsymposium.com). But the punch line really is that we now have access, every consumer in the United States, no matter how poor or rich you are, to some kind of drinking water filtration system. Whether it's an RO or it's carbon, there are a variety of ways to filter drinking water. It's critically important to human health and disease prevention, and most of us rarely think about it.
Dr. Rountree: This is a bit of a loaded question, but I see a fair number of patients that come in with a range of problems, and they've done a urinary mycotoxin test which turns out to be high for a mycotoxin. Their first assumption is: if I'm urinating out this toxin that comes from mold, I must live in a mold-damaged building. But then I ask them, “Well, tell me about where you live,” and we can't find any evidence that there's water damage going on. At that point I can't help but wonder: Could there be transient exposures in water or food, etc., that we don't know about, that we don't have an easy way of tracking? How common do you think that is, that people get exposed to substances like mycotoxins or metals as they are going about their daily lives? Sometimes I see weird metals in people's urine. Like antimony or chromium.
Dr. Cohen: Yes. You and I talked about chromium testing with patients. It's considered a human toxin, but there's chromium-6 and there's chromium-3. Well, many people take chromium-3 for diabetes control, but then we have chromium-6, that's the Erin Brockovich toxin from her movie. Both of these compounds may cause a false positive when running an outside lab test because they may not differentiate which chromium was identified. Years back I did a lot of testing for lots of stuff—blood, urine. What I've found in my own personal experience is that testing doesn't answer questions; it often raises more questions. So I really limit testing to a minimum, and I base it on my degree of clinical concern. And I think that's been good for not only my patients' pocketbooks, but also because I just think that the testing takes away finances from other healthy choices, like buying an NSF certified RO water filter for $275 bucks. I also think the results get so confusing because once you get an abnormal test, we're obligated to follow through, like we do in Western medicine. Most doctors are not trained to do environmental health evaluations to interpret toxin testing, which really needs to change. Doctors should really understand where their patients spend their time; they should know their air quality, drinking water source, and they should know how much processed food they eat. Those are the basics. And so I think if you are testing without getting that history—and again, the system doesn't really allow for a long history-taking—then you shouldn't be doing extensive toxin testing.
Dr. Rountree: I think I know what you're going to say, but I would extend that same question to testing for esoteric antibodies. I've seen patients who test positive for multiple different weird autoantibodies, not just ANA or cyclic citrullinated peptide, but antibodies against different tissue components or enzymes, but the question comes up “What does this really mean?” Sometimes it indicates cross reactivity to microbes or foods, but other times I wonder if we just make a lot of antibodies that are inconsequential.
Dr. Cohen: Correct. And I think your point is well taken, that you can test for a million different things, but what does it mean clinically? How is it going to change the management? And I like to learn from doctors who run interesting antibodies, because often I will learn something interesting, but unless it's clinically relevant, I don't know if doing a wide array always works. We need time to touch patients, discuss things with them, and dive into their lives to see where we can intervene. Did you know that 70% of people take some type of supplement for arthritis, and they don't reveal that to their doctors? They're embarrassed. They don't feel that the doctor will care or support this activity, or even make supplement recommendations. And so there are people that are actually doing themselves harm, and too many supplements, too much of a single supplement—I've had patients with selenosis from taking too much selenium from their 10 different protein bars, pills, and smoothy powders. Same with B6, and vitamin D3. Yes, you can actually take too much of a “good thing” and get hurt!
To Contact Dr. Aly Cohen
Aly Cohen, MD, FACR
Board-Certified Rheumatologist and Integrative Medicine
Physician and the Founder of Integrative Rheumatology Associates, P.C.,
Princeton, New Jersey, USA.
Website:
http://www.TheSmartHuman.com
www.AlyCohenMD.com
E-mail:
Aly@AlyCohenMD.com
Dr. Rountree: I actually saw an ad the other day—I'm sure you know about it, PrismRA®, it was called—for a test that determines the likelihood that somebody will respond to TNF-α inhibitors. I thought, well, that's an interesting evolution in therapeutics—a different take on precision medicine.
Dr. Cohen: Yes. I think cancer therapies really drive great science. Urgency really inspires great thinking. I mean, look at the mRNA vaccines and how this old technology was put into use for a worldwide pandemic—amazing! And I think new cancer therapies, the immunologic drugs called check-point inhibitors (CPIs), are very interesting. Studies show that many are changing survival outcomes for cancer survivors. But even so, as with almost all medications, there's no free lunch. CPIs have also been found to increase risk for autoimmune conditions. So there's always going to be a sort of risk-benefit ratio with everything we do and I talk about that in my book Non Toxic. As a rheumatologist, I've seen the biologics roll out over the past two decades and most have been quite miraculous. At this point, the medications effects from any specific drug is a bit like throwing spaghetti on the wall. And frankly, right now there is pretty much no biologic that's specific to any one human being. Of course, there are potential side effects that are specific to some biologics that you may want to avoid prescribing to a specific patient with that side effect risk, but in general, I have not come across any biologic that is specifically suited to any one specific person. My job is to make sure patients don't get hurt from medications or even supplements for that matter. I'm hopeful that new blood tests that look for drug efficacy before it actually goes into their bodies will really be a game changer. Sadly, I saw a recent study underway that's looking at family members of rheumatoid patients and giving them medications to prevent RA, even with no diagnosis of RA or personal symptoms! It made me want to cry. No kidding.
Dr. Rountree: Wow! Why not put them on a gluten-free diet or have them eat more salmon?
Dr. Cohen: Exactly! And I thought to myself, are we really at a place where we're using family history alone to justify a medication over promotion of lifestyle changes? I work with excellent cardiologists in my area. Occasionally, I'll see a new patient who was put on a statin just based on family history alone. So I call the cardiologist to discuss with them their logic for this. I say, why are you starting this medication simply because of family history, when you have someone who is willing to do the hard work of lifestyle change and who has no electrocardiogram or carotid artery findings on ultrasound, a negative computed tomography calcium score, and no personal history of stroke or myocardial infarction? Why are they on a statin with an low-density lipoprotein of 125? I like to understand their philosophy, and maybe help them to become more thoughtful, more judicious about prescribing medications that can cause real harm, especially when they have a motivated patient.
Dr. Rountree: I think we could go on for a long while, but that's probably a good stopping point for our readers right now. If somebody wants to follow you, do you have a website or preferred way to get in contact? Are you taking new patients? What do you see on the horizon for your career? New books? New initiatives? Anything like that?
Dr. Cohen: I wanted to tell you one more piece of rheumatology magic from an integrative medicine vs. Western perspective. Methotrexate, which is a gold-standard drug in rheumatology, is a great drug, and people don't understand, when I say a great drug, that I actually mean it's a great drug. It's been around for a while, a lot of years—60, 70 years—but it's interesting that it was taught, to me, to give as an oral medication, and I didn't even know it was an intramuscular option until maybe 7, 8 years ago. And what I realized, understanding how the microbiome works, is that you really don't want to throw pills into the gut if you don't have to. So in patients whom I initiate methotrexate for their illness, I always use the injectable form of methotrexate, not the oral version. I explain how the gut microbiome works and then I have them bring in the liquid methotrexate to show them how easy it is to use. This form is not only healthier for the gut, it's more efficient because it goes right into the body instead of traveling 24 feet of bowel and competing with food, other medications and even supplements for absorption. The gut is the window into our immune system, so disrupting the gut microbiome defeats the purpose of treating the immune system illness in the first place. This little piece of information, in my opinion, distinguishes Western rheumatology from integrative rheumatology. And there is a lot more than can be done in this manner in rheumatology to increase efficacy while reducing harm—particularly considering human evolution and human physiology with our recommendations. It's a win-win.
Dr. Rountree: That, to me, is what integrative medicine is all about, is that we don't throw out the baby with the bath water.
Dr. Cohen: Absolutely. I just wanted to share that. So yes, I'm still seeing patients in Princeton in my office. I grew up here. I do telemedicine, as well, so I see patients from literally all over the world, which is really fun. On my social media platform, The Smart Human, I'm posting on Facebook, Twitter, Instagram regularly to get practical environmental health and wellness information to as many people as I can. I also have a podcast called “The Smart Human,” where I get to talk to environmental health specialists, interesting physicians, and even environmental lawyers—just fascinating people. And I'm writing another book, which really gets to the heart of where I am with my career, my life, and my philosophy, which is about not just endocrine system effects, but immune system effects from our environment. It's a tough endeavor, but I'm hoping it'll be out in about a year and a half, so we'll see how that goes. There are lots of interesting educational projects in play right now—I'm excited to see what the future will bring!
Dr. Rountree: Great. It was wonderful to talk to you. I'm looking forward to seeing you in New York.▪
