Rheumatology and the Environment: An Integrative View

Interview with Dr. Aly Cohen published in ‘Alternative and Complementary Therapies’ Volume: 23 Issue 1: February 1, 2017*

Dedicated to both an integrative and environmental perspective on health, Dr. Aly Cohen is committed to helping patients and colleagues understand the environmental contribution to health and disease. Here, Dr. Cohen describes the environmental impact on rheumatologic disease typically seen in Western medical practices and what clinicians can do to both address and help raise awareness of this increasingly significant issue.


Q: What are some of the most common conditions that you see in your office today?

Dr. Cohen: In my clinical practice, I see people who have a wide variety of autoimmune diseases, including lupus, multiple sclerosis (MS), rheumatoid arthritis (RA), infectious arthritis, and osteoarthritis, as well as people suffering from conditions caused by various environmental chemical exposures, which is a specific area of interest of mine. During my 15 years of practice, I have witnessed what appears to be an overall increase in autoimmune diseases, not just because of better diagnostic capabilities by physicians, but also because there is a general ongoing increase in autoimmune diseases.1 There are currently about 80 specific autoimmune diseases, which include rheumatic diseases as well as autoimmune diseases of the gastrointestinal (GI) system, and endocrine autoimmune diseases such as with clinical and subclinical thyroid disease. As many as 9% of the U.S. population suffers from one of these autoimmune diseases, and about 1% of the population has been diagnosed with RA.

In fact, recent studies show there are 16,000 new cases of systemic lupus erythematosus (SLE) per year, which represents an increase as well. SLE, for example, has some very interesting identified factors that may predispose people to this disease, including Epstein–Barr virus, which a person may have been exposed to 10–20 years prior to the development of clinical symptoms and diagnosis. Smoking is also correlated with lupus, as well as a host of other autoimmune diseases such as RA and MS. Solvents, various chemicals and methylmercury exposure, have been correlated with SLE development. So there are some very interesting findings in these studies, which show that there is a correlation but certainly not direct causation at this time.

Q: What are some of the root causes of these conditions you have mentioned?

Dr. Cohen: One of the common denominators among a lot of the patients with autoimmune disease that I see has to do with life-style choices and environmental exposures. Clearly, what people choose to eat is a major issue when it comes to causing a host of health-related illnesses and not only metabolic disease but autoimmune diseases as well. Evidence from animal studies has shown that processed foods, which are high in sodium, have effects on the immune system such as increasing T helper cells (Th-17), which may cause autoimmune-related actions in the body. We also know that there are certain food-related components that increase the risk of inflammatory responses, such as bisphenol A (BPA). BPA is found in the epoxy resin lining of canned food, including most organic canned food and even canned baby food. BPA has been linked to a range of autoimmune issues and can trigger the immune system in many ways that cause disease (antigen presentation, dendritic cell activation, and innate and adaptive immune system effects).2

There is quite a negative contribution from our environment that, in my opinion, is creating a much lower threshold for autoimmune disease to take root, including what we put in, on, and around our bodies. The quality of the foods we eat, which may contain pesticide residues, food additives (coloring, emulsifiers, and preservatives), and lack of protective nutrients is a huge problem. Personal care products in the United States contain hundreds of chemicals, most of which have never been tested for safety prior to going to market, including those products geared to the most vulnerable in our population, such as children, pregnant women, and the growing fetus. Air pollutants are linked to many acute and chronic health issues such as asthma, chronic obstructive pulmonary disease exacerbations, cardiovascular disease, and stroke. Clean, safe water is grossly underestimated and misunderstood. Water source (e.g., tap, bottled, and well water), testing/regulation, and even transport (e.g., plastic bottles vs. glass and stainless steel) should really be discussed with every patient. The topic of water is very important because we drink more water than probably any medicine or food that goes into our body, and yet we really take it for granted. Even radiation exposure, which we are now greatly exposed to from the explosive growth in wireless technology, has evidence showing real health risks.

There are also other environmental issues that most physicians do not think about, including infectious causes for autoimmune disease, such as Epstein–Barr virus, as I mentioned previously, and we also know that some adjuvants in vaccinations may contribute to lupus flares. Occupational exposures, such as those that occur in the nail or beauty industry are linked to higher rates of autoimmune diseases due to the chemicals and solvents in the products that people in this industry handle on a daily basis. Silicone dust causes not only acute issues, such as pulmonary inflammation, but also symptoms of scleroderma and long-term skin changes, acroosteolysis, liver function changes, and even Raynaud’s syndrome.

Stress is another important environmental exposure that certainly affects the immune system. Whether stress makes one more prone to autoimmunity is difficult to decipher. However, certainly, when the immune system is compromised, many things can happen such as lupus flares, which can trigger many clinical problems. In my practice, I see patients who strongly believe that a traumatic experience in their lives set off the beginning of their health problems, which may or may not be autoimmune in nature, and I do not invalidate those personal stories. To me, that is a teachable moment to get patients to better manage stress; either to help quiet down any inflammatory response that is going on or to prevent one from happening. I do emphasize mind–body medicine with patients, including breath work, guided meditation, yoga, biofeedback, and other quieting effects for the immune system.

Q: Tell us about your integrative approach for treating people suffering from the conditions you have mentioned, including your environmental recommendations.

Dr. Cohen: First, I educate patients on the concept that our environment is filled with chemicals, and that these chemicals are not necessarily regulated by our government. This is a very important point because most patients—and actually, most colleagues, even in Western medicine training—do not know that there is a relationship between environmental chemicals, even with concentrations as low as 10–15 ppm or ppt, that can actually have effects on the human body. Perhaps the most well-studied group of chemicals are the endocrine disruptors, which affect the endocrine system, a system we know manages everything from growth and development in utero and during the toddler stage, as well as thyroid health and maintenance, bone growth, fertility, obesity, and insulin management.

As mentioned before, patients and colleagues need to be aware that these chemicals, number one, exist in huge amounts—upwards of 87,000 chemicals that we now have on the commercial market—and the majority of them have never been tested for safety or toxicity, and this is especially true for vulnerable populations, such as pregnant women, in utero exposure, and during childhood, as well as for the elderly and the immunocompromised. Once people understand these facts, then they are willing to listen to why changes are critical in life-style, why they have to be proactive in their own lives, and that I am there to help them along the way.

Certainly, the most obvious life-style change—not necessarily the easiest but the most obvious life-style change—is diet because if you go back to Hippocrates in 460 BC, when he said, “Let food be thy medicine and medicine be thy food,” we know that certain foods can either enhance the human body’s health or diminish it. The discussion of using only good-quality foods, free of pesticides, free of GMO ingredients, and free of additives such as coloring, preservatives, and fillers, is quite important to human health. Interestingly, there are certain foods that bind to environmental chemicals. For instance, we know that quercetin binds methyl mercury, as does zinc, which is found in pumpkin seeds. We know Lactobacillus binds lead and methyl mercury. This takes us back to the idea of food as medicine, and that is how I work with patients—by increasing intake of foods that we know bind harmful environmental chemicals, as well as teaching them about avoidance of those chemicals. Improving the health of the gut microbiome is also key to an effective and properly functioning immune system.

If you believe in evolution and understand that we, as modern-day humans, have been evolving for millions of years, we really have not evolved the ability to handle the 87,000 chemicals that have been introduced over the past approximately 150 years. This is a very short time frame for the body to manage all of these new chemicals. So to avoid them and eat clean food really takes the onus off of the body and detoxification mechanisms. Clean and healthy food lightens up the load for the body to be able to function properly and maintain homeostasis.

So food is where I start my conversation when I talk with patients about how to eat and drink cleanly. Water is another topic, which requires a lot of discussion with patients in terms of where they get their water. Is it tap water? Is it well water? Has that water been tested? How often do they use filters? What type of filters? In terms of bottled water, of course it is important to ask people what are their water containers made from? Are they stainless steel, glass, plastic? These are all very important topics of conversation that can take a long time, and many Western doctors do not know how to broach this conversation. They also do not know what direction to give patients, and that is why I started The Smart Human, an educational environmental health platform to give physicians the tools to direct their patients on reducing environmental exposures in a practical, nonjudgmental way. Patients can best follow on Facebook: The Smart Human for vetted health information, practical tips, and best resources.

The next topic I usually bring up with patients besides what food they are eating and what they are drinking is the quality of the air they are breathing. I ask if they are plugging in chemicals to “freshen” their air—are they using carpet cleaners, candles, perfumes, cleaning products, vinyl flooring, home furnishings, and any other sources of synthetic chemicals that are aerating in and around the home. It is very important to discuss how air quality matters. I often use the example that when we breathe in air, the oxygen goes right into our bloodstream. So why would we not assume that synthetic chemicals that are in the air, in cleaning products, perfumes, and fragrances are not going right into our body immediately and as seemlessly as oxygen? These are issues that can be controlled at the home level and in the workplace as well.

I also discuss personal-care products with patients, which people have a harder time changing because they are attached to whatever they have been using for years; deodorant or creams, lotions, makeup, aftershave, shampoos, conditioners, nail polish, and nail gels. These are the kinds of things that really make up people’s identity. I tend to cover this as a later topic, using vetted tools and resources so that people are able to make those changes comfortably over a reasonable period of time.

Exercise is key to eliminating toxins from the body. So, I work with patients on increasing aerobic exercise in order to sweat. Stress is also a very important environmental exposure that can be managed on many levels. Sleep is not only restorative for the mind and for dreaming and feeling refreshed, but good quality and quantity of sleep is critical to managing the immune system and for clearance of environmental chemicals. There is an actual lymph system in the brain that clears toxins, and it has been studied quite well.3 We do not usually think about the impact of sleep when we only get four or five hours a night—it is underestimated as a contributor to our overall health.

Synthetic light is another exposure I discuss with patients. There was a study recently regarding synthetic lights shortening telomeres and causing premature aging,4 and this is actually something that people can manage. In my personal office, I do not have any synthetic fluorescent light, which gives off radiation, number one, but it has also been found to affect telomere length in animal studies. This is the type of information I post on my Facebook page, The Smart Human. I post them in a way that is not only approachable and reasonable, but also accessible and easy to understand by the average person who has no medical or scientific background. I have found that when adults, teens, parents, and even colleagues are given the right tools and vetted information to make healthy life-style changes, they actually do make them. They just need the guidance, and that is what The Smart Human on Facebook, Instagram, and Twitter does.

One of the biggest aspects of my job is dealing with chronic pain, whether that is fibromyalgia, RA, or any of the autoimmune diseases, or post-viral issues that I see in my office. Chronic pain is something that really can be managed without opioids, which has become a huge crisis in the United States. Pain can be managed with other resources that are often available locally. I know that integrative resources can be scarce for some patients, but certainly breath work is free and has remarkable effects. The 4–7–8 breathing technique, which I learned from my training with Dr. Weil and his colleagues at the Arizona Center for Integrative Medicine, University of Arizona (Tucson, AZ), can be enormously beneficial for reducing stress for both children and adults. We even practice it together in my office. I also suggest guided imagery for those who cannot quieten their mind and do meditation on their own, such as myself. Guided meditation now has several smart phone apps: Relax and Rest and Zen are wonderful. These are very low-cost and accessible to many. There is also free guided meditation through Kaiser Permanente online, not requiring a phone or a smartphone, which is important for many patients in terms of socioeconomic accessibility. Mindfulness discussion and taking the time to care for oneself is something that many people often do not think about as well. Many patients are constantly giving to others, so this is an important discussion to have—how people handle the dynamics in their families, how they handle personal stress and the needs of other people around them.

There is not a lot of training for Western doctors, and even for integrative physicians, regarding asking the right questions that are helpful for patients to understand their own environment. Some of the questions that I think are important to ask a patient are what kind of job do they have, and where do they spend most of their time? Are there harmful chemicals in their work and home environment? Are they adequately protected? What is their water source? Well water versus tap water and any filtration? How old is their home, and have they had any home exposures to chemicals that would be important, such as new flooring or new furniture? Also, I ask about their dietary habits, cooking practices, and food storage. Knowing to ask these questions is very important. I have many environmental health questions built into an intake form on my practice website, AlyCohenMD.com. When you have those questions already answered, it makes it a lot easier when communicating with the patient with an allotted time of only 15–20 minutes. There are certainly many PDFs online that can be printed out that help with these types of questions. There are very good forms for asthma management, particularly for children and great forms on how to ask the right questions in regards to people’s exposure issues for respiratory disease, pulmonary inflammation, and allergies; it is not always just pollen and the change of seasons that cause people to have inflammatory lung and respiratory issues.

Q: What would you like integrative medicine clinicians to keep in mind about the cause and treatment of rheumatologic conditions in particular?

Dr. Cohen: Since autoimmunity is really the breakdown of self-tolerance, we want to build up each individual’s tolerance. We want them to feel that they have control over building and strengthening their immune system in a way that really works for them. With autoimmunity, in particular, we want to be careful how much we strengthen the patient’s immune system because this could worsen their clinical disease; their immune system is directed to act upon itself. So there is a balance when treating autoimmunity not just to support the immune system, but also to make sure it is not activated actually to cause more harm. When choosing supplements and medications, it is very important that integrative doctors understand the causative agents they are treating so as not to set the immune system off in the wrong direction. Not all inflammation has the same upstream mechanism of disease.