Season 7, Episode 3: The Connection Between Chronic Conditions and Environmental Chemicals with Dr. Aly Cohen

Evelyne: Yes, I’m really excited. Today we’ll be talking about the connection between immune disrupting chemicals and chronic conditions, including autoimmune disease. And before we start today, what’s lighting you up this week?

Dr. Aly Cohen: Gosh, what’s lighting me up? Well, my son got into college, so I guess that’s lighting me up.

Evelyne: Congratulations.

Dr. Aly Cohen: Thank you, it was just his voice. So, these are the little wins, especially as a busy mom. You know, you like to see your kids happy.

Evelyne: That’s amazing. So, before we dive in, just a little background for our listeners. Doctor Aly Cohen is a triple board-certified physician in rheumatology, internal medicine and integrative medicine, and one of the country’s leading medical and legal experts in environmental health. She’s on the faculty of the Academy of Integrative Health and Medicine, Southern California University of Health Sciences, and the University of California, Irvine, where she creates and manages the environmental medicine curriculum for doctors and researchers.

She’s a coauthor of Nontoxic: Guide to Living Healthy in a Chemical World and co-editor of the textbook Integrative Environmental Medicine. She has collaborated with the environmental working group Cancer, Schmancer, and other disease prevention organizations, and has received countless awards for her work in health education. She hosts the Smart Human podcast and sees patients in her medical practice in Princeton, New Jersey.

So, I’d love to hear more about how you became so passionate about this topic of environmental toxins. But before that, how did you get into rheumatology?

Dr. Aly Cohen: Wow, so no one’s really asked me that question in a long time. I think, like with many people who are probably listening, I think we get affected by the people that we work with and train with.

And I happened to work with pretty remarkable people in my training program. I was in New York City, at Beth Israel Hospital Medical Center, and they had a program with Montefiore Medical Center and Albert Einstein. And I was very intrigued by my mentors. And so, when the positions opened up for that fellowship, I was just really excited about it.

But we don’t always know where our choices are going or where they’re going to lead us, which rotations are going to make us more interested in one topic or another. So that’s how we got into it. I love the immune system. I thought it was remarkable. I loved anthropology from college. And so, as I kind of picked up new information along the way in new training, it’s really informed how I manage patients, the questions I ask, what I’m thinking about and, and sort of how to do better. So, it all sort of adds up.

Evelyne: And then how did you come to specialize in environmental chemicals? Can you share a little bit of the story they shared in your book?

Dr. Aly Cohen: Sure. So, I was finishing my rheumatology fellowship about 15 years ago, and, I was newly married. I had a new puppy who was a golden retriever. He was my firstborn. And then, along came two young kids, and I was very busy. And all of a sudden, the dog started not feeling well. And I thought golden retriever probably chewed something. You know, I’ll wait till it comes out the other end or something like that. And long story short, he was diagnosed with something called autoimmune hepatitis.

And, what’s so interesting about autoimmune hepatitis, which is where, again the body attacks itself at the liver, was that it’s really rare in dogs and even more so in golden retrievers. And as an autoimmune disease specialist at the time, having finished training, it was so heartbreaking and ironic that this dog had something so unusual within my own field.

And so, I felt very helpless. But then I also was heartbroken. And so, I started to explore what might have caused him to get sick. I thought about his drinking water. We live on a farm in New Jersey, and at the time I thought, well, you know, maybe, maybe there was a break in the piping in the community and maybe some of the farm chemicals, pesticides got into his water. His dog food could have been contaminated, or his flea and tick collar chemicals could have been a problem. Or even the plastic toy that he actually chewed on and slept with all day long. And so as I was kind of looking through and kind of doing an environmental survey on this dog, trying to figure out what made him sick and potentially how our family could be sick, too, I started to learn about what is now called environmental health, how environment affects human health.

At the time, I was realizing there was no protections for animals and pets, no required regulation, no testing for any of the products that they use or we use for them. But what led into the work I do now is that I really started to see, that there were no regulations on chemicals in human environments in the United States.

And in fact, I was so blown away that it took me down a rabbit hole of trying to figure out if this was really true, because here I’d been through medical school, residency, never heard that our environment, drinking water, air quality has cosmetic chemicals, cleaning products, industrial chemicals, pet food, packaging, chemicals could have anything to do with human health, let alone immune system disorders.

And that is how I sort of got to this place over 15 years, is trying to figure this out. And how to apply it to my patients and to my own family. So, it really became a journey for me. And I hope to put all of this in what I do for training and for doctors and for high school students and the books I write in the podcast. I’m trying to give information that I wish I had back then, in order to inform me.

Evelyne: Yeah, absolutely. So, in your book, you talk about immune disrupting chemicals, and usually the term that we hear more is endocrine disrupting chemicals. So, I’d love to hear a little bit more about that. How do these chemicals actually affect our immune system? And I’m curious if you could go into the different ones because, for example, BPA is cleared from the body within a few hours, right? Whereas these forever chemicals like PFAs are not. And so, I’m curious, like what effects do they have?

Dr. Aly Cohen: So, I’ve written two books. One is a textbook for Oxford on endocrine disrupting chemicals. First I had to understand what they even were, then I partnered with a renowned reproductive biologist, Dr Frederick vom Saal, who was actually responsible for helping to get Bisphenol A, or BPA, out of plastic out of baby bottles in the US in 2012. So he’s a remarkable mentor and friend who worked with me on two books for Oxford. And so as I was trying to figure out what the problems were and then what the specific chemicals that have been tested because there’s so few, there’s no required regulations for any of the chemicals, to be tested for safety or toxicity in any of the products that we use in the United States.

And I think people just don’t, like I didn’t fully grasp that, that there’s no required testing by manufacturing. So as I was learning that there was an actual group of academics around the world that are studying these chemicals on their own, and then started to learn that there was this chemical group that they designated as endocrine disrupting chemicals, which are chemicals that are capable of disrupting the normal workings of hormones in the human body.

And of course, we need our hormones for growth and development, fertility, to manage insulin, which is a hormone, and to manage blood sugars, we need hormones for estrogen and androgens to develop a male or female baby child. But also to manage menarche and puberty and even menopause. So we have all these hormones that are so conserved through evolution, that only a very tiny, tiny amount of these hormones are needed to do vast physiologic changes in the human body over the course of our lifetime, from conception till death.

These endocrine disrupting chemicals, which are so fascinating, have become, over the last 15 years, remarkably visible in terms of the public. Part of that had to do with the two books that I wrote with Frederick vom Saal. What was so intriguing over the last five years is that we also know that many of these chemicals affect the immune system.

And they may also have endocrine effects as well. But remember, the endocrine system and the immune system in the human body, like so many systems, do not stay siloed. They have crosstalk. They communicate. We know, for example, when we treat patients with cancer, with certain drugs, like Car T-cell therapies, that we know that one of the indications of success from that cancer treatment is actually the development of rheumatoid arthritis or an autoimmune disease or immune system problems.

And that’s actually the risk benefit of being treated for cancer. So we know that these systems talk, they communicate, but many of the chemicals that we now know as endocrine disrupting chemicals, including Bisphenol A, phthalates, a group of thousands of chemicals, the polyfluoroalkyls, which are the forever chemicals that stick around a long period of time, they all have immune system health effects.

And the reason it’s so important to my career, my work, my training in rheumatology is that I’m seeing, as we are seeing across the literature, the medical literature, an epidemic of immune system and autoimmune disease cases. And we’re seeing this in younger people with no family history, which really adds to the weight of environment as a major contributor for the development of these new cases. And so that’s where this all really came from, is, is kind of the integrative medicine training, which is diet, nutrition and sleep and all that, plus the formal Western rheumatology training and then really lopping on a big dose of environmental health information and all that seemed to really coalesce and intersect for this new book. And the work I’m doing now.

Evelyne: Thank you. Can you share, from a science point of view, what is actually going on in the immune system? Is it that like certain signals are being turned on or off? Is it affecting B cells, T cells? How are these chemicals actually changing the immune system?

Dr. Aly Cohen: Right. Well, first of all, the immune system is so unbelievably complex. I mean, it’s just so complex. We have both the innate and the humoral immunity. So very, very conserved, evolutionary systems, the innate and also the humoral, which is really the response with antibodies, B cells. I’m very much simplifying it because it is just so unbelievably complex. But what we’ve seen with some of these immune disrupting chemicals are similar to the way in which BPA, for example, as an example of many chemicals that can have effects, we know it’s disrupting.

There’s no set pathway, but we know that, for instance, BPA can certainly upregulate T cells and NF kappa beta. We know that, at the cellular level in the cytosol, we have inflammasome activity, which increases sort of the surveillance of environmental chemicals that come into the cell at the cellular level.

We have organ level involvement when it comes to even just the signaling or even hormones comes from the immune system. And then we have the clinical flares that can happen when there’s immune system disruption from immune disrupting chemicals. So it’s not just at the cellular level, organ level, but we also have flares of inflammatory response to exposures to some chemicals, even on the clinical level. So there’s different ways to look at the responses.

But the thing about immune disrupting chemicals is that the immune system is throughout the body. It’s not just when we think of bone marrow, we think of pushing out stem cells that turn into one class of cells or another. We have receptors for the immune system throughout the body, including the brain. So we have the neuroendocrine immune system components as well. So that’s how there are brain effects from many of these chemicals that work on the immune system.

And some of the most conserved, hormones in our human evolution, like estrogen and testosterone, which are the oldest really evolutionarily, have receptors for the immune system. So estrogen itself can affect a variety of complex issues in the human body. And we know that these receptors are on white cells, beta cells, We know that they’re on different mucosal membranes, especially the, you know, the gulp system of the GI tract. And so again, we know that many of these chemicals, BPA is the one I discuss most in the book, along with perfluoroalkyl and phthalates. But they have the ability to increase the inflammatory markers.

Remember, these are foreign substances. The human body has been evolving for over 4.5 million years. And these chemicals, the vast majority of the 95,000 that we now wrap our head around in terms of numbers, because the number is constantly growing. They’ve only been introduced into the human existence, modern day living over 75 years. So if you think about 4.5 million years and 75 years with this exposure level, you can understand how the immune system is so perturbed and unable to effectively evolve to manage not just blocking the chemicals into the body, but also breakdown of exogenens through the liver and even some of the breakdown products of many of these chemicals are inflammatory as well. We see this with trichloroethylene. That’s the Camp Lejeune chemical, and a variety of other chemicals.

And again, every chemical has its own properties, such as half life, such as ability to break down in one organ or another there are effects of the hosts, such as comorbidities, renal function, liver function, lymphatic system components. So there’s a problem not only with the host potentially in getting rid of the exposure, but the actual chemical itself has its own properties in terms of how it works, where its toxicity resides. And so all of that makes it very much problematic to the human body. So that’s really where the angle is with when I discuss these chemicals, but I certainly dive into them a little bit deeper, a little more mechanistic, when you get into the book, of course.

Evelyne: Yeah. And I’m glad you brought up the immune system because we are living in like a soup of chemicals. Right? Like in a way that we’ve never, ever evolutionarily been exposed to before. And I think sometimes you hear people saying like, oh, our liver and kidneys do a great job detoxifying everything, but we actually don’t necessarily because we haven’t evolved to clear all of that. Is that right?

Dr. Aly Cohen: Yeah, that’s absolutely true. I mean, the idea is that, our body does a great job of adapting, right? It kind of manages hunger, it manages thirst, it sort of adapts to the world around it. But we’ve had so many chemicals sort of infused into us, not just through what we breathe in terms of phthalates and chemicals in the air, VOCs, air pollutants, ozone. We’ve also had influx into what we drink and what we eat, so from an ingestion route. We have dermal exposure, such as personal care products, cleaning products, solvents that get through our skin. We have intravaginal exposures. So the chemicals that are in tampons and feminine care products, which include antimicrobials, bleach, rayon and other plastics instead of cotton, plasticizers, and perfumes, which are phthalates.

And a lot of these really have been linked to a lot of, not only changes in fetus from pregnancy exposure, but really also have not just endocrine, but immune disrupting chemical properties. So we have such an influx to our body, we’re a sponge, essentially. Humans are sponges for all of these chemicals. So we create mixtures and that’s, aside from just what we get from our food and food chemicals. We have over 13,000 food additives in our food system. But we also take medications and medications have their own properties. And you could argue that these medications are often a soup from just the vast majority that are not even tested amongst other meds before being put to market.

So we are soups. And the whole premise is that we know that these chemicals, many of them at least have some harm to the immune system, and certainly endocrine system. So the idea is instead of worrying about each chemical property in each of the 95,000 and learning about the chemicals, really, how do you stop them from getting into the body? Where do they reside? And then how can you get them out of your system in a very sane and reasonable way? And that’s in order to reduce risk for so many of the inflammatory conditions that we now see.

Evelyne: Yeah. And we will get into that because it can be very complex and overwhelming. And this is a practitioner-focused podcast. So I think a lot of our practitioners do talk about this, but I want to get into some of the nuances. And I’m curious for you as a rheumatologist, do you have any stories that stand out to you from your practice when it came to a toxic exposure? Somebody came to you for rheumatoid arthritis or another condition that they would go to you for and something that you wouldn’t have initially thought was the culprit turned out to be the issue.

Dr. Aly Cohen: Yeah. So I look at all humans, including myself, and definitely my two teenage sons, as toxic before proven otherwise in the sense that we are always exposed to chemicals. Sometimes they’re short-lived, sometimes they’re longer, like my kids on the lacrosse field that’s synthetic turf. Or, maybe you went to a birthday party and had cake. There’s all different exposures. Life is fluid, and we are really exposed even through driving through different areas. We are getting different levels of air pollution. So the idea that anyone coming through my practice as a rheumatologist, I’ve now formulated a way and I share this in the book as well, in terms of an environmental health assessment, what should we be asking patients so that we can learn more about their actual distance?

And really, you want to be thinking about what they put in, on, and around their bodies on a routine basis. You can always get into the lifestyle components, which we’ll talk about, how much does this person exercise and sweat? How much does this person sleep where they can remove many chemicals during sleep, through the lymphatic system, which we now have really great science on in terms of clearance at night while we sleep.

But really thinking even about stress and light pollution, noise pollution. There’s so many things to think about. What I like to take on when patients come through is not just understanding their history of their illness or their symptoms. And then the routine family history, which I found has very little to do with where what we’re seeing in human health now in terms of ailments. But I like to get that history from them. Where do you get your drinking water and do you filter it? Very important when it comes to the contaminants that are in our drinking water system. And I talk very clearly that our water system is quite, quite dirty and quite worrisome in terms of human health conditions. And how easy it is to fix is why I’m asking the question.

We now have solutions to these questions, which any practitioner can ask and solve. I ask, how much they sleep? Do they get restful sleep? Are they considering organic foods? USDA organic regulation is the only thing we have in the US food system. And it was designed in the 1990s, but it didn’t even really take effect until decades later in 2002. So organic food actually has real teeth in terms of quality of food we take in because there are thousands of pesticides and fertilizer, chemicals and genetically modified, ingredients that are not allowed in the US, organic, USDA organic food system. So I really want to know what they drink and if they filter and what they eat and the quality of their food, and do they exercise and do they look up their personal care products on any of the free apps that we now have available and doctors and clinicians can share with their patients?

I put that all together, because to me, if you’re going to ask the question, you really want to have reasonable solutions, and you don’t need to go necessarily back to school. Although I will get this in, I do find it to be really horrible that we’re not teaching this material in 2025 in any of the health programs, I’ve even offered 40 hours of free curriculum since I’m already doing this work at three programs post-physician training. Why aren’t they doing this in medical school training as part of curriculum for prevention? And I think that’s the problem. Medical schools don’t treat to prevention. They treat ailments and pharmacologic solutions. But the prevention component is completely, intentionally, I think, left out.

Evelyne: Do they not want it? Does it not fit in?

Dr. Aly Cohen: Yeah. No they don’t want it. Because and these are people, deans of medical schools that I’m actually friendly with, who like the work that I’m doing and believe that this material is absolutely valid, but they are forced to fit it into a contrived system where there’s no room for this material. And listen, I am the farthest thing from a conspiracy theorist, but I will tell you that most funding for medical school training programs comes from the pharmaceutical industry. So, it’s not hard to put together why prevention is such an unweighted, unbalanced component of medical training. Because we want to keep people healthy in my world. But that’s not necessarily the way, the industry works.

Evelyne: I want to go back to what I had asked earlier about any cool stories from your practice about, I don’t know, maybe it was a lead exposure or mercury or something like weird or uncommon maybe?

Dr. Aly Cohen: Sure. So I would say that I’ve had exposures over the years that have certainly been a component of too much of an occupational risk, or, you know, certainly children who have had lead exposure but didn’t know it and, you know, basically showed up in their lives with ADHD and attention deficit disorder. So we know many of these chemicals can have effects on mental health and behavior. Lead is one of the most common ones for misdiagnosed ADHD, believe it or not. And I encourage people to think that through.

But the idea is that when I’m doing a lot of my questioning in my surveys, I’m also considering I don’t do a lot of environmental health chemical testing routinely because I want people to spend their money on the solutions, not on the testing, which is often pricey because it’s not always available. I actually picked some of the most conventional labs, LabCorp Quest, and I put the codes, ICD-10 codes for the most basic chemicals that people can order through insurance, which I want people to harness their own insurance, not necessarily use outside labs if they’re looking for some of these chemicals. And I think they’re done very well, actually, in these labs.

So I’ve caught a variety of chemicals over the years. One of the cases that I talk about in the book, and I have a lot of patient cases, which I think a lot of clinicians can completely relate to. But one of them was a woman who came in with mouth ulcers and she had been through ten years of mouth ulcers on and off. And of course, everyone thinks HSV or some type of very routine, canker sores or in my world, lupus, you know, should I be thinking about mouth ulcers and photosensitivity and all of that workup, which we did. But we really couldn’t find anything specific until I was doing environmental, chemical, screenings, which I do with all patients at the first visit through conventional lab testing.

And I caught arsenic and, arsenic was picked up in the blood and in the urine. And so it then it refocused my environmental health survey to her. So now, instead of such broad topics, I was narrowing in. Well, where is arsenic found. Arsenic is found in rice. Not only in white rice but brown rice even more so because the sheath of rice held on to arsenic very tightly. It’s also found in drinking water at bed levels, often above what’s considered, healthy and that’s a real problem even though it’s under the Safe Drinking Water act.

And so as I was asking her, culturally, she had rice 4 or 5 times a day and had been doing this because her family was Hispanic, and so this is part of their culture. And she had a lot of rice in her culture and also unfiltered water. And so we began the process of trying to figure out how to move to an organic form of rice, cutting down the volume, thinking about drinking water. And she had a reverse osmosis water filter, which is what I recommend. They’re not terribly expensive anymore, and I really encouraged that and watched her levels drop over time. And with those levels, it happened that her mouth ulcers, which can be associated with arsenic exposure also became fewer and far between. And so these are the kinds of things where you don’t always know the outcome is going to turn out that way, but you do your best detective work. And rheumatologists are known for detective work. But when you add in that environmental health knowledge, or at least the questions to ask with very reasonable directions to go with, I think it makes me a better practitioner. And I think it helps the patients. So I think that’s what the take home is, is let’s expand our understanding of the problems that can be associated with illness and use that as another tool.

Evelyne: Yeah, I want to get into testing a little bit more, because I think I was surprised to read that a lot of these tests can be covered by insurance. I did have mercury tested one time through LabCorp, I believe, but otherwise I’ve always, you know, gone to some of the functional medicine type labs for toxin testing and heavy metal testing. And so I’m wondering if you could share what are the top ones that you can get covered by conventional insurance.

Dr. Aly Cohen: So everything in medicine can be covered generally speaking with the right codes to have a reason for those codes. I’m talking about lab testing. I don’t know why people don’t do more testing, but I think you really also need to know who’s interpreting those results. Everything about medicine is, you don’t order a test unless you know how to interpret it. That’s what I was taught in residency. When it comes to some of the most basic exposures, for instance, I send every patient who comes through, I do a whole blood testing for cadmium, arsenic, lead and mercury. Four of the most common exposure heavy metals, and each one of them has a recognizable source, and each one of them has a recognizable way of reducing that exposure.

So when I put that in the book, along with very basic cancer screenings for certain markers, what I’m almost sharing is years of clinical experience and the question of why are we not testing more under people’s insurance and not requiring them to get extra blood testing through expensive consults? I just want people to really be thinking, how do you utilize their finances better? Because then they could put the money again towards a reverse osmosis water filter, or to buy USDA organic frozen foods, or to get a massage or to get therapy.

So again, I do my screenings. I code them appropriately. I even put the codes in the book, for patients to bring to their own practitioners. I want patients to be really savvy consumers and advocate for themselves and have agency over their bodies.

Evelyne: That’s great. Thank you for sharing. And I meant to say conventional lab tests, not conventional insurance before.

Dr. Aly Cohen: Well both are really conventional I guess. I don’t know. Use the system to your advantage. I mean I’m always one to say, well, I’m paying a huge deductible and lots of insurance. Why aren’t we utilizing that to our prevention of disease instead of just always running around chasing after we have a diagnosis, you know?

Evelyne: Absolutely. So you talk about this Four A’s framework which is Assess, Avoid, Add and Allow. Can you talk a little bit more about how practitioners can implement that with their patients?

Dr. Aly Cohen: Yeah. Thank you for asking that. So again, having done a lot of work over the last ten years, trying to figure out the best way to navigate or to teach patients and colleagues and students how to navigate this pretty heavy duty topic, I really wanted to simplify it so that people would embrace it. And so I came up with the Four A’s of environmental health navigation. And it’s pretty down to earth, right.

It’s Assess, which includes a very reasonable environmental health survey, which we have in the book. But Assess, you really need to know what it is you’re exposed to, where it might lurk, to have the second A, which is Avoid. So it’s Assess, then you need to Avoid or swap, you could say swap because, you know, if I wanted to avoid mercury in my lipstick, phthalates in my deodorant, canned foods with BPA, nonstick pan chemicals like perfluoroalkyls, I can now avoid because I know where they come from. And I could even swap out to stainless steel pan, different deodorant, different lipstick, and switch to frozen foods instead of BPA in cans.

So you need to assess to get the Avoid in there and swap. And really, that makes sense to me. The third thing, which I think a lot of practitioners listening may not understand or may not know because I certainly didn’t, is that we know that we can get epigenetic changes from exposures of all kinds. We can even have it in stress, right? We know from the Dutch famine data from World War II that, even in utero exposure and trauma from starvation had very different outcomes in women who were starved or had no food versus those that were not. And we saw that in generations to follow that in utero exposure from those that stressor was actually really, played out into more and more chronic health conditions. So we know that even those exposures in utero can really be a problem.

And so we have these epigenetic changes that potentially can affect DNA methylation and either express genes that are harmful, that create clinical illness or not. So our epigenome is affected in a good way or bad way, but certainly we can add nutritional value into our lives that really offset that epigenomic changes such as DNA methylation hyper and hypermethylation, which affects gene expression. So the idea being that we now have great information on folic acid or Vitamin B9 and how that can offset BPA and phthalates. We know that Omega-3 fatty acids, if they’re done properly, and I have a whole thing about vetted supplements and how to understand how to, you know, the whole wild, wild west of supplementation is just crazy.

And how omegas, done well can be really important not only to offsetting epigenomic changes in methylation, but also decrease inflammation. And I talk about that in the book and the studies involving that. But we have quercetin that’s an antioxidant similar to Vitamin C that offsets the antioxidant loss. When it comes to inflammation, there’s just an iodine that sits in the thyroid offset, some of the flu or alcohol chemicals that are the carbon fluoride bonds that are in the perfluoroalkyls by definition, and very difficult to break. But certainly iodine protects the thyroid.

So I go into some of these nutritional components of food or supplements, which may not be enough in foods, given our modern day food system, and why certain supplements that I call human fertilizer really is essential from birth till death. And that’s a very dramatic statement, but it’s true. You’re under nutrified, and that Add piece, we have Assess, Avoid, Add.

The Add is the component that we’re putting into our bodies to help, even at the cellular level, to help the body thrive. So, you can take away all the things that annoy and trigger the immune system. We have to put in the nutritional pieces to let the body heal itself and help detoxify it.

And then the fourth A is really there to show again the fluidity of life. The colored hair that you decide you really want to have, despite the fact that you write books on environmental health, the birthday parties and having cake, the travel that you don’t want to miss out on, even if you are not going to be around your favorite personal care products or have access to certain healthy foods that you like, life is fluid. There’s lots of things we can control. There’s certainly lots of things we can’t. And so, the Allow is just to give people a little bit of a deep breath on this topic and to do the very best you can. And I kind of point to the 80/20 rule. You know, you do 80% as much as you can and 20% is sort of life. And if you can get up to 90/10, all the power to you. But it might be fluid as well.

Evelyne: Yes. Agreed. And I do think initially it can be very overwhelming for people. I think at this point, because I’ve been learning this for so long, I feel like I’ve made so many changes over the last ten, 15 years. And so, I don’t obsess about it in any kind of way, but I feel like people can get very obsessive, right? Because it is extremely overwhelming. And there are so many things to change.

So as practitioners, where do you advise that the first step is to start with patients out of all of the changes, like whether it’s like food, water, personal care or environment?

Dr. Aly Cohen: I think with practitioners, number one, I think it’s more important for the practitioner, in my opinion, to know what they know. And in other words, they are going to want to have the answers if they’re going to want to ask the question. So, if you really feel that food is a reasonable, very, very common, very popular question is do you eat processed or ultra processed foods, you’re going to want to have the answer that maybe that’s not a really healthy choice.

Maybe you want to opt in some frozen vegetables that are organic because they’re cheaper and they’re available at big box stores across the US and really democratized the food system in many ways being frozen USDA organic. I think that that’s a great answer, having people from a cost perspective not be overwhelmed and tell them that frozen, organic foods are often not only organic and low in pesticides, but very high in nutrition because they’re flash frozen.

So that’s a question a doctor or a clinician can say to their patients – what do you eat? Let’s do a food diary and let’s just talk about breakfast, lunch, dinner, what you’re eating. Maybe that’s an area to go into besides just trying out a gluten free diet, which I’ve seen remarkable changes in clinically with patients.

They don’t have to be tested and have a positive celiac test. They can simply just feel better being gluten-free. It’s remarkable and it’s easy, but I think food is a big one that people think about. Then I would move into drinking water. I think drinking water is the most under-recognized contributor to human health conditions in many ways. We take water from any restaurant that we sit down at.

We don’t prioritize water. We spend billions of dollars on cooking and diet books and talk about different Whole30 and Mediterranean diets. No doubt food is important. But I think we’re missing the boat when it comes to water, because we need water every single day or else we die. We are made up of water, about 85 to 90% water.

And we just don’t think much about it because we don’t know much about it. So, when I talk about it in the book, I’m talking about what you can share with your patient to make them understand the why that water matters and that filtration is not cost prohibitive. So, you want to say, what is the problem and how to fix it?

But I think as a practitioner listening to this, that you may want to just have the basics for what the solutions are before asking the questions, then you’ll feel more confident in what you’re doing. You might even want to do this in your own house, in your own family. I encourage doctors and the doctors I’m training everything that I’m teaching, you should apply to your own life and see how it feels, see how it works, and I think that’s the best way to go is food, water, looking at personal care products. I think give them the apps. They’re free. Give them the websites, they’re free. Maybe, I do this with my patient. I’ll look up their lipstick with them in the room and show them how easy it is. They’re usually totally tickled by this. They love it.

I think it’s a learning experience for both practitioners and patients. But you might want to know a little bit of something about something before you sort of dive into the questions.

Evelyne: Yeah. And I think most of the practitioners I work with here in San Diego are like naturopathic doctors, integrative and functional medicine practitioners. But I also think that some practitioners, maybe if they specialize in, say like gut health and we know there’s like a microbiome connection, right, with these chemicals, or specialize in hormone health. But then we might kind of like, we know that this part is important, but it might not come up immediately because we’re trying to work on all these other things. So I think it’s always a good reminder to keep this as part of the conversation.

And with the water, you said earlier that you recommend reverse osmosis. What’s the reason why?

Dr. Aly Cohen: There’s a variety of filtration systems. I do talk about that extensively because not every filtration system fits every person, their family, their economics, their location, again, you could be in a rental apartment. Although I will argue that every rental that I’ve ever worked with patients, they were allowed to have an ARO filter, by the way, especially with a prescription from a physician. So, I’m very much an advocate for my patients in those settings.

But the filtration systems are, look, I have kids. Kid is going to go off to college. I’d love to put an ARO system underneath their kitchen dorm sink if they have one. But what if they don’t? It’s not like I’m going to be running in there with a bunch, I certainly won’t be allowed to by my son. But the idea is that pitchers are, perhaps, a really good way to manage a situation where you don’t have control over the entire situation.

So, any filtration is better than none, is what I would argue that the filtration systems that are part of the pitchers, the faucets, the refrigerator doors are called carbon block or activated carbon basically. But they essentially do a modest level of cleaning water because the water runs through very quickly. We don’t have time to wait around always for a pitcher to fill up, so they are very, very, modest in the way they clean water that runs through them.

Whereas reverse osmosis, by definition, the material is so tightly woven that it’s the pore size. It’s almost like it catches it by size, the contaminants and reverse osmosis, which was available in the 70s. My dad’s a nephrologist. He’s still practicing at 85. He brought nephrology to New Jersey 50 years ago in the 70s. And they are, as nephrologists, required to have reverse osmosis water, federally regulated water for dialysis units, and they get managed and checked every month. Even now, my dad’s 85 and still has to walk this crew through and have water testing.

They were designed back in the 70s, specifically before all these contaminants came into our life, ironically, were single celled organisms, so viruses and bacteria, molds and fungi and all that kind of thing. And that was to protect these immunocompromised dialysis patients from getting infections. But what’s so interesting is that reverse osmosis, the pore size is so small that it also catches the bigger compounds, the phthalates, the perfluoroalkyls, the bisphenols, even to some degree, the VOC is a volatile organic compound.

And so the idea was that it was designed so far back really has much more applicability now that we are so inundated with these chemicals and so reverse osmosis fills up, you know, three canisters, lots of surface area. It’s underneath your kitchen sink, which is what I prefer, because then you have to keep filling it up. And essentially they run like $300 and they’re very clean and they’re quite good. And they do take off quite a bit of the perfluoroalkyls, which, I interviewed the Duke University lab, with Heather Stapleton as the director. And she was my guest on my podcast, The Smart Human. And we went through that. She tests these filters at the Duke University lab, and, it’s quite remarkable that that’s the most aggressive way to clean water that we have available.

Evelyne: And is there still a concern with getting the minerals filtered out of there, too?

Dr. Aly Cohen: So I get this question a lot. And so what I say is that, listen, yes, minerals are removed because of reverse osmosis. This material doesn’t know the difference between calcium, magnesium, whatever potassium and, say, phthalates and lead and arsenic. So it’s a baby out with the bathwater that being said, water is never and has never been the source of human nutrition, just never been the source of nutrition.

And so you can simply have a glass of water of reverse osmosis, filtered water with the wonderful meal salad, fruits, vegetables. And that’s how you’ll get what you need. You can also add them in some systems even have a system to do that. I don’t prefer that. I don’t recommend it. I’d rather people spend their money buying fruits and vegetables instead of worrying about what goes back into the water. I often get that question. I really do emphasize the fact that that’s not the source of any real nutrition is water.

Evelyne: Okay, that’s great to know. You talked about diet and supplements a little bit. And then you mentioned sweat and sleep. I want to go talk about the sweating a little bit. So I know that there have been some studies on sauna use. I think it was Stephen Genius who did some of those, I know I always say his name wrong.

Dr. Aly Cohen: It’s like potato, potato there. I’m not sure really there, but. But yeah. So lots of studies when 9/11. Lots of studies with officers in New York City and methamphetamines were tested back in the 70s and 80s.

In terms of sweating and what comes out on sweat, the studies are really hard to conduct, but what we have available and what we know about human physiology is that the body is pretty remarkable at removing some of these chemicals that are still synthetic and release it into human evolution. Right? But it’s one of the best mechanisms that we have and can utilize and can harness or detoxifying what we don’t even know what we’re exposed to things that we can’t control all the time.

So I do encourage under safe guidance and safe recommendations, aerobic exercise or for my patients, rheumatology patients chair exercises, upper body. You don’t have to necessarily have weight-bearing exercises. Certainly sauna, I like old-fashioned sauna, not necessarily infrared for a variety of reasons. But I think, old-fashioned sauna is if you’re in good enough health.

And certainly pregnant women have to be very, very cautious or not use them. But the idea is that we have ways to utilize, detoxification pathways, whether it’s from eating nutrition that bolster sulforaphane and glucosinolates and all of the liver detoxifying, stage two conjugation, mechanisms in the liver, whether it’s the sweating, whether it’s supporting our kidney function or our liver function or our lymphatic systems, these are ways that humans can manage in a very toxic world.

And evidence shows, we know that, that when people change their lifestyle, when people change their choices of foods and water quality and cosmetics, we do know that these chemicals go down in the human body. Certainly chemicals and food. We have great studies on that in human studies, not just animal studies. So there’s plenty of them in the book just to really support the notion that we don’t have to be wacky, we don’t have to do high colonics, we don’t have to do crazy stuff to really help reduce the body burden of these exposures and reduce our risk for health issues.

Evelyne: And with the sweating, I remember, I was in my detox class with Deanna Minich, she was my professor for that class and we talked about how some toxins and I can’t remember now are preferentially excreted like through sweat. And I can’t remember now, but is there a difference between like sauna use, and you mentioned traditional versus infrared versus exercise for sweating.

Dr. Aly Cohen: Well, infrared doesn’t make us sweat as much. I mean, it’s sort of a deeper layers I worry about very small and probably should be done further of risk of skin cancers because of the sort of penetration of some of the infrared sauna.

Evelyne: Interesting.

Dr. Aly Cohen: And again, the jury’s out on that, but I did write about that in the first textbook. And infrared was never part of human evolution. And everything I talk about typically tips a hat tip towards anthropology and evolution and sort of how do we how do we best manage? We utilize our cellular tissues. We utilize vasodilation and water distribution and chemicals across the kidney nephrons. I mean, we are utilize using such cellular levels of exchange. And I just think that regular sauna, if it’s within the realm of appropriate use and great hydration before and after, you can’t get better than that when it comes to really trying to remove some of these chemicals.

When I travel and I have very little control over some of the foods I’m eating at a plastics and I can’t always get my favorite water. And I forget my water bottle and blah, blah, blah, I come home and I try to really focus for a good week or two on being better and being better. Better choices. I have a sauna I put in. It’s really tiny, but it was something I really felt strongly about. It’s conventional and it was built without any glue and it was built without any EMF, and it was built without any wood that has cyanide and any other kind of wood sealants.

So, even those little nuances that I wanted to incorporate, I’ve done it over time. I’ve done it over time and through education, and I’ve really not panicked my way through this. I’m trying to do this in a reasonable way. Try to teach others.

Evelyne: Yeah, that’s great. So that we’re not overwhelmed, but that we’re informed. I think that’s how you put it right.

Dr. Aly Cohen: We don’t know who’s going to develop what. We do know that there are connections to diseases from dysbiosis of the gut, from exposures from chlorinated drinking water. I mean, that alone should tell people that we’re knocking off good guys, right? So the idea is to be empowered and to not do anything out of fear and impulse.

I really do believe it’s not a diet. This is about incorporating really appropriate changes and making smarter choices over time.

Evelyne: Do you feel that since you’re a rheumatologist, this environmental medicine component has been the missing piece to the puzzle, or are there other advances in the last 20 years that you’ve been practicing that you feel like have made a big difference?

Dr. Aly Cohen: I have to say I’m biased because I just feel like I just know too much that was left out of my training. I know too much that was left out. It’s not to say that I don’t use medications. I think that some of these medications have changed. Certainly in rheumatology, rheumatoid arthritis patients do not get this disfigured mostly. I mean, back in the day, 25 years ago, I guess it’s when I graduate fellowship. I mean, we had nothing to offer, and now we have these wonderful pharmaceuticals.

The problem that I see is that that’s the only tool being offered to clinicians as a solution. And I think that I use those drugs, but I don’t use them as reflexively as I could or should from my training, and that we have this whole world of letting the body heal in an appropriate way by taking away things that we know irritate the immune system, and adding in nutrition that we’re missing from basically childhood because we don’t even test for these nutritional levels when we need them most in childhood. So that’s sort of how I look at it. I’m triaging patients to see how soon I have to onboard medications, if they’re needed. But certainly assessing the need for that is, takes a little bit of a gestalt so you don’t get let anyone get hurt.

And that’s been the really big part of it. And then also, there’s so much interesting stuff coming down the pipe. You know, we didn’t know much about the gut microbiome until 15, 20 years ago. It certainly has become such a major part of my work with patients. In my writing I have a whole chapter on it, in terms of chemicals and how it affects the gut. But then we’re learning more about vagal nerve stimulation. We’re learning about the vagal nerves connection to the gut brain connection. I think we’re going to be learning so much more about small chain fatty acids and how they affect human health.

Mind body practices, I think, have gotten so much more popular and so effective if done correctly. So there’s a lot of exciting stuff coming down the pike. I just would love, love, love for people to really pay attention to this particular area as well.

Evelyne: Yeah, definitely. So I love environmental medicine conferences and I’ve been like into this topic for a really long time, just like you. And it made me wonder last night as I was preparing to talk to you, has anything gotten better because to me, it seems like the awareness has increased exponentially. And I think I do, sort of, and you probably feel the same way. You’re kind of in a bubble, right? Because we are in the field that we’re in.

And so we’re around people and conferences where this is spoken about. But is there more legislation around this is anything actually changing? Is drinking water improving? What is happening on that side of it?

Dr. Aly Cohen: Yeah. It’s so slow. Oh, it’s so slow and it’s so slow that I feel the urgency because we are now having so many people coming through, at least my practice and around the world, such a high rate of autoimmune diseases, 7 to 14% worldwide. And it’s increasing in terms of autoimmune diseases. The changes are so slow, I would prefer them to be faster. We just in April 2024, there were, four fast peripheral chemicals. I think two more to follow that are going to be added to the Safe Drinking Water Act restrictions for municipal tap water, which affects 160,000 wastewater treatment plants that serve about 85% of the US population.

So yeah, that’s a win. We now know that these chemicals and there are now 15,000 of them at least. So taking four out by managing them like the other 91 only since 1975 before really is so slow. It’s a snail’s pace compared to the generations that are moving quickly. Our kids and our grandkids, which is the urgency of us doing it ourselves.

And so, no matter which policies are slowly put into place or taken off the table, by the way, which a lot of them are, and no matter how slow or fast our politicians work or administration works or EPA tries to get going, we are going to be suffering from the stagnancy of this, the stagnation of all of this.

So the idea is that we have to do this ourselves. And what I mean by ourselves is doctors need to be exploring these topics in a way that they’re comfortable, that they learn slowly but surely, that they have good information to share, and that we do this and share this with our patients to do for themselves. So we’re not waiting for policy to affect our health.

It just is too slow for what we’re seeing in actual clinical practice, in my opinion. So is it getting better? I think awareness is getting better. I think people are paying attention. I think we need to be careful about different sources and where we get our information right. TikTok wouldn’t be my first place to go, but there are even some reasonable people on TikTok, so maybe it is, I don’t know, but the idea is you have to choose your messenger, who you believe, and you have to decide if you’re going to implement what you learn from that person that you believe in.

And so all of that takes, I think, a lot of thought. But yeah, I think awareness is key. But then finding the true messenger, that you learn from and your mentors. I’ve had many you have many. You know, we want to we want to learn from people that we trust. So I think that’s really big part of this is, is really what’s the truth, right? Where’s the science lead us.

Evelyne: Thank you for sharing that. Before I ask you our final questions, I want to go back to something around lab testing, because in your book, you did mention that you also recommend nutrient testing. And I remember also learning from Deanna about how there’s that inverse relationship between minerals and heavy metals.

And so, with your patients specifically like for rheumatology, are you measuring minerals and other vitamin status with everybody? Can you talk a little more about that?

Dr. Aly Cohen: Yeah. Of course. I mean, there’s just so much you can test. I certainly check vitamin D levels and keep people at a high normal level, 60 to 80, 60 to 90 levels. Assuming that they’re not hyper parathyroid or any of those other calcium abnormalities. But, that’s good for the bones. It’s good for the heart. It’s good for the immune system. We know that vitamin D is so critical to human health. That’s just one of the many nutrients that I really consider managing now. Testing for magnesium and testing for zinc, these are also very variable in terms like vitamin D is fat soluble, which sticks around. So when we get a level of typically it takes a while to go up or down anyway, that’s not to be said for some of the other nutrients that we need every day.

So we need iodine every day. We need zinc and certain micronutrients like magnesium and amino acids. So the idea is I can’t test for everything, and not everything needs to be tested. What I prefer, again, is the solution. What’s the solution? A really great multivitamin that has 150 micrograms of iodine every day to sit in the thyroid and protect it from many environmental chemicals like so thiocyanate and nitrate and perchlorate.

So the thyroid needs iodine to protect it. We don’t get it from food, we don’t get it routinely. We don’t get in the amounts we need. So really, the solutions, as I mentioned in a whole chapter on human fertilizer and nutrition is to add is that we really need some very basic supplements.

And those supplements are the very least every human should be on. And one of them is a great multivitamin. And I’ve even tested myself before and after certain vitamins. And measured whether or not I need a little more iodine than someone next to me, or because my diet doesn’t have meat in it, should I have more iron?

And those are things that I think is where personalized medicine comes in. It’s not really scalable, unfortunately, but we’re trying and I think that’s why education and I even have courses on my website, The Smart Human, on heavy metals and testing and integrative. I have a bunch of little courses that I’m trying to get this out there to the masses so that they or practitioners get that bits of information to help change the clinical practice or to help patients say, this is the code for this, I’d love it if you would test that, if you don’t mind, to their doctor or health care practitioner.

So again, empowering people to be proactive, have agency over their body to speak up, to test where it seems reasonable and to take supplements that we know are missing in the food system and not really part of even the best diets. I think that’s all part of this messaging of taking care of ourselves.

Evelyne: Yeah, and I’m glad you brought up the iodine and thyroid piece and the relationship with the floral alcohol substances, because my iodine was like a little bit on the lower end when I had it tested recently, and I was a little bit surprised. But I also I don’t take my multivitamin every single day.

But when I saw that, I was like, okay.

Dr. Aly Cohen: Yeah, it washes out. So, it’s one of those things where, and then we have to be compliant. So it’s not just knowing what to take, getting the vitamins that are high quality, third party tested, vetted, taking them every day and then getting tested. I mean, this is work.

And I think, the average American doesn’t even have time to keep up a job or two jobs and kids. And life is busy. So, you know, again, this work of being healthy is something that we as practitioners can help our patients, better with compliance. I mean, I even have pill cases that I choose that cost nothing, but they help patients understand how compliance leads to outcomes and so if you have great stuff and you never take it, what’s the point.

Right. So I think it’s sort of coaching along with great information that really does have the best outcomes. So that’s what I found. And so yeah, I’m glad you brought that up.

Evelyne: Thank you for sharing that. Okay. I just have three rapid fire questions that we ask every guest that I want to wrap up with. So what are your three favorite supplements for yourself? I’m going to guess it’s a multi.

Dr. Aly Cohen: Yeah. So I’m a big fan of a vetted multi. But I vet them very carefully. I do think vitamin D3 is just so easy to fix. I think omega threes are incredibly difficult to find good brands. I can only name probably couple 2 or 3 max that I like the way they’re distilled and managed.

And a probiotic if you’re not getting probiotic food. So I mean, I think there are some things you can get from foods like selenium from a Brazil nut. But, you know, in reality, I’m not going to have a Brazil nut every day in my busy life. So again, thinking about and being honest with your own lifestyle and understanding where to fit these in, that’s those are some of the supplements I really feel strongly about.

But there are several others that are personalized to whatever I might have, like migraines or, in my past, but also things like that support or what else? Iron. You know, I eat a narrow diet and all of a sudden I was iron deficient out of nowhere. And now I realize where that came from.

So I think it’s good to test yourself. Doctors, clinicians, listening, have a little fun. I get like 14 tubes of blood every couple of months just for fun. And I test things that I’m trying out. No, really, I think a little bit of that Supersize Me. I don’t know if you’ve seen that documentary, but, the idea is that we have a really interesting and a blessing of a career to be able to do this to our bodies and see what where we’re at.

And it will help us to be better doctors. I think, when we understand what we’re doing to ourselves. So I encourage that.

Evelyne: Absolutely. And what are your favorite health practices to keep you healthy and resilient and balanced?

Dr. Aly Cohen: I have to run. I run, run, run, run, run. I like to run. And when I haven’t run because the weather’s so cold here in New Jersey, it really has an effect on my mental health. There’s no question. It’s not just the lack of sunlight and all that, but there’s running is a real big part of how I feel good and get ready for my day. And you see me punching as I’m jogging down the street, like someone’s like, put her away. But no, really, it’s its honestly where I get so much freedom in my brain. So, and flow of ideas. So, yeah, I like to run and I, I like to be with my pets.

I would say my kids, but they’re teenage boys, so I’m not sure if I want to be around them a lot these days. They certainly don’t want to be around me, but my pets are my unconditional hearts. And, you know, I write about my dog, but there’s nothing better than pets.

And my poor husband, he’s like, at the bottom of the list. But I do like him.

Evelyne: I did read the sweet dedication you wrote to him in the book. I always love reading people’s dedications.

Dr. Aly Cohen: He paid me. Just kidding.

Evelyne: And last question for you. What is something you’ve changed your mind about through all of your years in this field?

Dr. Aly Cohen: I’ve been disillusioned with medicine, but I’ve also been reinvigorated by medicine. I’ve been disillusioned with medicine in terms of the lack of training. But then I have a relative who is very sick and one of the best hospitals in the country, and it inspires me to want to love medicine again, to see how a team can work so beautifully, even in conventional Western medicine, at the level that we’re talking about, with really sick, sick patients.

So, I’ve come full circle, but I do wish we had more prevention. And I feel a little robbed in my training. And I feel sad that I’ve had to do this a lot on my own. And a lot of doctors listening and, and health care providers have to do it on their own. But, I think it’s where we’re at, and, and patients are counting on us to do right by them.

I’m inspired now to keep going because I really see differences in patients that that take on these type of lifestyle changes and stuff. I guess I’m still in the game and I still like what I do, and I’m inspired to teach other people. So, my heart is still there.

Evelyne: Yeah, I love that. And I love all of the teaching that you’re doing. It’s like you want to get into high schools. You’re teaching at different programs to inspire the next generation, not just of the general public, but also practitioners. So that’s great.

Dr. Aly Cohen: What else is there to do? I’ve got two kids. I want my kids to be healthy. Everyone listening wants to have long, healthy lives. I think we all play a role. And I just want to get to the younger, youngest generation people that we can because then that’s when their habits are changed for life. So it makes sense.

Evelyne: Yeah. Well thank you, Aly. Thank you so much. This was a great conversation. And I loved your book. I thought it was very comprehensive. So thank you so much.

Dr. Aly Cohen: Thank you, Evelyne. And again, people can find The Smart Human. Please follow on all the different platforms. Listen to my podcast, which I have wonderful guests that I think a lot of your practitioners will recognize and take a couple courses if you think that that would be helpful, because these are the things that bolster our knowledge and help our patient care. So thank you for having me, Evelyne. I really do appreciate it.

Evelyne: Thank you so much. And thank you for tuning in to conversations for health. Check out the show notes for resources from today’s episode. Please share this podcast with your colleagues. Follow, rate or leave a review wherever you listen. And thank you for designing a well world with us.

Voiceover: This is Conversations For Health with Evelyne Lambrecht, dedicated to engaging discussions with industry experts, exploring evidence based, cutting edge research and practical tips.