Podcast Brain Fog & Cognitive Decline Case Study: Functional Medicine Series

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Dr. Andrew Wong 

Welcome friends to a special series on the Capitol Integrative Health podcast. I’m your host, Dr. Andrew Huang. And this is a podcast that is dedicated to exploring the root causes of both disease and wellness. I am honored to be a co founder of Capitol Integrative Health Clinic in Washington DC area with a mission to create a global revolution in health care by educating, leading and inspiring people towards optimal health and true well being. One of the key modalities we utilize in our clinic to help patients and be of service is functional medicine. We’re excited to offer you this series is an insightful look into functional medicine, otherwise known as root cause resolution medicine, and walk me through case studies that emphasize how we think about and approach holistic care with our patients. Welcome to today’s episode, where we walk through a case on brain health using a functional medicine approach. Jose, who will call him Jose is a 58 year old male who had a concussion while playing football as a teenager. He works as a software engineer, which often involves long hours of sitting and minimal physical activity. In the winter, Jose experiences seasonal depression. He also has a family history of diabetes where and his grandfather died of Alzheimer’s disease. His body mass index is 29, which is considered overweight. Jose has a multitude of brain symptoms. He started to frequently experience memory lapses a couple of years ago, such as forgetting his appointments, misplacing objects, or even struggling to recall recent conversations or details when he’s talking with friends. He finds it challenging to stay focused for extended periods of time, and often feels a sense of mental fog or brain fog. He has noticed also a change in his mood, including increased irritability and feels more easily overwhelmed by everyday stressors. Jose also doesn’t sleep very well. He sleeps about four to five hours a night and has difficulty staying asleep. And he feels tired in the morning when he wakes up. In terms of Jose’s lifestyle, Jose recently started a keto diet or ketogenic diet for weight loss. Now, for those of you who don’t know what a keto diet is, typically it is about 80% fat, although there are modified versions of this where it’s less fat and a little bit more protein. So he does eat a high fat diet, but also a high protein diet as well. So he’s eating red meat and keto products. And we can talk a little bit more about that as we go through this. He’s drinking alcohol three to four times a week. Sometimes there are shots like fruity shots, sometimes it’s It’s wine or beer, mostly I think beer and, and sangria. In terms of stress, his family and finances are primary sources of stress. And in terms of movement, he is sedentary, he really doesn’t move very much. He mostly has a sedentary job and is sitting at his desk, an old knee injury and chronic back pain have really prevented him from working out regularly. So for Jose, there’s there’s a lot of questions to ask, really, I want to ask him about his football plan years as a teenager, was he wearing a helmet? What was the mechanism of injury, things like that, a lot of times with traumatic brain injury. Problems with with brain injuries, in terms of memory loss, and brain fog and mental fog can come up years or decades after that original trauma. So so a concussion is a TBI or traumatic brain injury. And we want to kind of ask him teach about that. And also about any further, further injuries that he’s had, whether playing football or other sports. Soccer is another really common one for people that are hitting the ball, that’s also trauma to the head. Also motor vehicle accidents, or MBAs can be really, really important, especially if the person suffered whiplash or things like that, and you’re bumping into part of their car, things like that. So that that would be very important. And then during his his teenager and young adult years, did he have any trouble with memory or cognition or not. So just trying to see the trajectory of the disease process there. We also know that he does experience seasonal depression in the winter. So another thing medically that we always want to ask if someone has depression is just to make sure that they’re not suicidal. We know that people with traumatic brain injuries and brain fog and a history of concussion significantly, and if they start having memory lapses, they do potentially have an increased risk of suicide. One of the things that happens is that the brain gets less functional. There’s an imbalance in brain chemicals and executive function and a lot of times for some people, unfortunately, this leads to suicide. In fact, there’s actually something called chronic traumatic encephalopathy, which is CTE and this is seen and 98% of college football players and nine The 9% of NFL National Football League players, so even people that you know didn’t get to the college or pro ranks, if they’re playing football for a long period of time, you have to wonder, you know, do they have CTE? Do they have chronic traumatic encephalopathy? So one of the things again, tying in that CTE to risk of suicide, you know, if someone has any sort of anxiety, depression, things like that, they have a history of brain injury, you have to ask them to make sure they’re not having suicidal ideation. Also, we know that that his grandfather died of Alzheimer’s disease. So we also want to know, you know, when he when he died of Alzheimer’s disease, was it later in life, which is like, you know, 80 plus, or was it kind of relatively early like in his 60s, Jose’s only 58, he started developing brain related symptoms at 56. So, if his grandfather had a relatively early period where he actually died of Alzheimer’s disease, that this would be a cause for concern, and more aggressive treatment would be warranted, basically. So those are some of the questions I would ask. And then also from a perspective of the nutrition, ketogenic diet, you know, I think a lot of times we fall into this trap, we meaning you know, all of us fall into this trap of, well, it’s a diet, so must be healthy. But really, the question is not really, is the diet healthy or not? But is this particular nutritional plan, right, for Jose, and that’s called Personalized functional nutrition? Is this diet? Or is this nutritional plan, good for Jose, given his health histories, given the season in his life, given kind of what’s going on with him? So I think for a ketogenic diet, for weight loss, you know, there is some evidence that it can be very helpful, at least in the short term, there’s also a concern, I think, though, if someone’s eating a high protein diet and a high fat diet, especially a high protein diet, I would say that if he’s not drinking, if he’s not eating rather enough green veggies and, and fiber in his diet, then potentially that could lead to an imbalance in the gut microbiome, which is not good for gut inflammation or brain inflammation. So I want to make sure that you know, is he eating is eating vegetables eating fruits, but but especially is he eating green vegetables, because that and fermented foods, because those would be things that would be really, really helpful for him if he’s eating like a high protein diet. Also, we know that a ketogenic, ketogenic diet is very high in fats, right, it’s 50 6070 80% fat. Now, a classic keto diet is 80% fat. So we want to understand how much fat he’s eating really in his diet. And then what are the qualities of those fats, there’s different types of fats, now, the quality of the fats will determine in large part, not not all, but in large part, it will really influence the health of the brain. So the brain is about 60% fat, to literally the brain tissues, 60% fat, so you need that fuel source that that fat that makes up the brain to be of good quality. Now we have different types of fats that we can eat. So we really have things like what are called you know, you know, good fats, you know, it’s not a moral judgment or anything, but you know, good fats. And then we have kind of bad fats or inflammatory fat. So the fats that are generally considered good for the most part would be things like olive oil, and avocado oil, and coconut oil, to some degree, depending on their genetics can can be very helpful. And then some oils from nuts and things like that, that can be very helpful. And then I think from a perspective of keto, and you know, you know, some saturated fat could actually be very helpful things like lard and things like that could be helpful in moderation, then other fats that get oxidized more easily. And oxidation basically means rust. So not literal rust, but basically inflammation and oxidative stress, that will inflame the tissues, and in this case, inflamed the brain. So we don’t want really oils, we don’t want to use oils that when flame the body, the blood vessels in the brain when these these type of oils are called inflammatory oils. These are the web seemingly are very healthy vegetable seed oil. So vegetable seed oils are heated, they’re denature. They’re processed, and basically, they’re there, they oxidized the body. So these are things like corn oil, and sunflower seed oil and safflower seed oil. cottonseed oil, so basically the ones that are found in most most packaged foods, most restaurant foods, you have to really look at the label there. Most of the time, you’re not going to eat your tortilla chip or your Nacho chip or your crackers with with olive oil. You know, there are some packages that do have that and you have to like kind of look for that ideally, if you’re going to eat those snacks, but but Goodwill’s are going to be really, really important.

Dr. Andrew Wong 

Also, I should mention that, you know, omega three fatty acids and other types of fats and that’s going to be found in in fish and supplementally and either fish oil or algae oil or krill oil or things like that. So basically, he’s probably needing a little bit too much high protein, high fat for the amount of veggies he’s eating, if he’s not eating, you know, if he’s not eating at least three to five veggies a day. So that’s I would focus on nutrition. The other thing I would be wondering for him is, is alcohol now there was some way that we were taught in school, which is that whatever people will tell you for the amount of alcohol that they’re drinking, just double it, you know, people don’t really, they kind of underestimate what they’re drinking. So I want to ask him about alcohol. And you know, drinking alcohol three to four times a week, that seems like, you know, maybe it’s okay, because, but it’s not okay, because alcohol is really a neurotoxin. And if he has brain fog, and fatigue, and memory loss, and depression, and all these different things, and a history of TBI, in terms of concussion, alcohol is toxic for the brain. So now we know, based on various studies, one study was done in 2019, published in The Lancet that showed that really no amount of alcohol is safe for us. Now, doesn’t mean you can’t enjoy something at a cocktail party or a birthday or anniversary or something like that. But we can really understand that alcohol is toxic for the brain. And just to understand that, even as we kind of take it down our pipe, you know, so alcohol is toxic for the brain. So for someone like him, you know, three to four times a week, I don’t even know how many drinks that is, you know, he might be drinking one a at a time. But then is it one glass of wine? Or is it one bottle of wine, you know, how much is he drinking. So we do want to ask him about the amount he’s drinking and try to limit that basically. And then I’d love to ask him about has he tried PT before physical therapy, we know that one of the best ways to reduce inflammation is physical activity. And he does have some old back pain and old knee injury. But that doesn’t mean he can’t exercise, it doesn’t mean he can’t kind of engage the body again, and try to reduce that inflammation, including not only joint inflammation, but brain inflammation, again, kind of zooming out, again, looking at functional medicine as a systems biology approach to things. If you remember that, that game, I think it’s by Milton Bradley, I believe called Operation right where it’s like doctor and you basically have, you know, the hip bone connected to the knee bone, the knee bone connected to the calf, and all that stuff, the arm is connected the shoulder, so in that same way the biology is affected, that’s affected, like the joint, let’s say for him is connected to the brain and the brain is connected the gut. So So really, the biological systems are connected in the same way that the operation game, you know, connects all the different joints and muscles on that on that board game there. So what I mean by that is that by exercising his muscles and joints in a safe way, in a supervised way with a qualified professional, he may be able to reduce his his brain inflammation by increasing his healthy oils by increasing his protein, combining it with vegetables. And by increasing his gut health and microbiome health in that way, by increasing his gut health is able to also help his brain health because again, the body and systems are all connected. So these are the kinds of questions I would I would ask him, I would also be wondering functionally about how his work is affected? Does he live with people? Does he have a family? How his home life is affected? What kind of things? Can he still do? What kind of things can he do now? So basically, what he cares about so if he cares about maybe playing with his kids or going out and play golf, or you know, whatever he enjoys doing, I’d want to kind of understand what motivates him to make lifestyle changes because we’re going to recommend a lot of things for Jose and he’s not going to do any of them if it doesn’t mean anything for him so so if we said something like you know, reducing alcohol would decrease brain inflammation and that will allow you to be more present for your kids that and he hears about that and hopefully that that would be very helpful for Jose so lifestyle so we’re getting into lifestyle again so I think the number one two and three thing for him is maybe number one and two but we’re just we’re just give give us two but is to stop drinking alcohol he’s he’s drinking too much for for anyone but also he’s drinking too much for his brain health. So I think it would be a zero alcohol policy for him ideally, maybe he has one on his birthday or something like that. But I think basically alcohol as a neurotoxin should be eliminated from from his diet. He could drink something like a seltzer water with a little bit of fruit flavor in there or lemon water or something like that. You could depending on the situation. One favorite of mine is something called cinnamon tea which it’s kind of tastes sugary but but isn’t sugary because cinnamon is just sweet but it actually lowers blood sugar so we can we can check his blood sugar to I think anything that doesn’t have alcohol in it. And also I would say another thing that sort of a detail point is that if he didn’t want to drink if he didn’t want to give up alcohol completely, you know some of the fruity drinks are actually not very good because they raise the blood sugar even more things like Sangria unfortunately, or you know, fruity drinks would actually raise it more than wine would like red wine. So if you couldn’t give up alcohol completely, you know, maybe a little bit of a Pinot Noir or something like that, that has a high antioxidant capacity, but maybe once or twice a week at most, because we know also from the United Kingdom study, which is a different study that I’m citing here is that more than two times a week of drinking, I’m sorry, more than two drinks a week total, two drinks a week total is associated in the literature with mild cognitive impairment. So he clearly has started to get some potential mild cognitive impairment here. So two drinks a week of red wine would be the minimum, the minimum, the maximum, I should say, that I recommend, and the idea would be zero for him actually, for alcohol. The other thing that’s really, really important is that sleep is very important to regenerate the brain. So during deep sleep, there’s something called beta amyloid. Now, beta amyloid is a collection of basically proteins that aggregate together and form beta amyloid beta amyloid has been linked to it hasn’t been proven to be the cause of but it’s been linked to Alzheimer’s dementia. So one thing that happens in deep sleep, which usually happens in the first half of the of the of the night, basically, is when most of the deep sleep is happening for us. The beta amyloid gets detoxified by the body by something called the glymphatic system of the glial lymph system. And that was recently discovered within the last 10 years or so, I think right here on the East Coast, but in any case, we can we can look at someone like Jose, that is having trouble sleeping, and we can kind of see from a functional end of things that he’s probably not detoxifying his beta amyloid. So one of the big things is, can he sleep better. And going back to some of the other episodes, you’re gonna see a pattern here with, if he’s having trouble sleeping, and he’s having cognitive issues, we know that one of the big things that’s going to increase his risk of cognitive impairment and dementia is actually CPAP, sleep apnea, sleep apnea, or OSA, obstructive sleep apnea. So we want to make sure that he is sleeping well, we want to make sure he doesn’t have sleep apnea, we refer him for a sleep study. We also want to make sure that, you know, why is he having difficulty staying asleep, if he’s drinking that alcohol, chances are maybe he’s having gastro esophageal reflux disease, or GERD. So instead of taking a Tums or an antacid or a proton pump inhibitor, like the purple pill or something, maybe what we want to do is have them stop drinking alcohol, so he has no reflux, and then he can sleep better. So reflux is another big sleep interrupter. We also think about for a guy like Jose, maybe his prostate starting to get enlarged. So one of the big things is, you know, is he having urinary frequency. But again, if he’s chugging a bunch of alcohol at night, that’s going to make him pee more, it’s going to decrease his deep sleep, and it’s going to reduce his ability for his brain to detoxify the beta amyloid. So I think the sleep will be very important, too. So so so far, we’re talking about cutting back on the alcohol, we’re talking about improving your sleep ruling out some medical conditions there. And then if he’s having difficulty staying asleep, you know, why is he having difficulty staying asleep, you know, what is the reason for that, and trying to treat that and address that. I think the the other thing, and this is kind of beyond medicine here, but I’m trying to, I think it goes more to the mental health side too, is he does have a lot of stress, as well. So maybe he needs to see a counselor, maybe he needs to see a mental health therapist.

Dr. Andrew Wong 

And then another big thing would be to go see physical therapy, you know, he’s probably not someone that I would say would be really that safe to kind of start exercising on his own with chronic back pain and knee injury. But after a medical evaluation, you know, referring to physical therapy, and working on a slow but but gradual way to really help with with things here, from the muscles and bones perspective and really reducing inflammation so, so really like everyone here that’s listening, and I’d like Jose to think about exercise not as something he has to do, but it’s really one of the best anti inflammatory treatments that he could he could give himself. So exercise as an anti inflammatory treatment, I think it’s really, really important for him and as he gets better with things with his back and knee and just kind of getting into it more gradually, that can really help improve his functioning, which which should also help his brain as well. So those are some of the lifestyle recommendations. We’re recommending, we recommend here. Now testing, I would definitely go towards, again, some of the hormone testing, certainly testosterone and certainly prostate testing and thyroid testing, but certainly for someone like Jose his BMI is 29. That means he’s overweight. So I’d be concerned about his blood sugar. I’d want to make sure he doesn’t have diabetes. He does have a family history of diabetes. So we want to check something called to him We’ll win a one C test. That’s a test that measures basically how sticky or how sugary the red blood cells are. So as there’s more sugar that sticks around in our system, some of that inevitably sticks to the red blood cells, and we call that like constellated hemoglobin test, or any one C test. And optimally, I’d like that under 5.5%, or even under 5.3%. So there’s different kinds of ways we can interpret these tests. But a hemoglobin would see a fasting insulin would be very important for a person like this. And ideally, getting that below five to eight would be very helpful. And then thinking, thinking like metabolically as well, things like uric acid and cholesterol would be very important to liver test, kidney test. So some of the basic tests that we do, but that and hormones. And then I think from an alcohol perspective, because again, alcohol is a diuretic, just like in our previous patient that had coffee, really looking at the magnesium level. Magnesium is a really important mineral that’s important with blood sugar metabolism and cardiovascular health and mood and energy and a lot of different things. And magnesium would be very helpful for him as well to to look at that level. And then omega three fatty acid levels as well would be very helpful for him. Now, from a functional brain perspective, we do something called the quantitative EEG tests are evoked test here at our clinic, and this is something that I look at as a lab test for the brain otherwise known as a cognitive therapy. So we know that people have colonoscopies, and we know that we can also give people cognitive therapies to see how they’re doing from a mental health perspective. So I’d be concerned about Jose with his family history of dementia with his symptoms that are consistent with mild cognitive impairment, we would consider doing potentially an MRI of the brain, we would consider doing a mocha square, which is a Montreal cognitive assessment, which is a paper or online test that can be done to screen for MCI also called mild cognitive impairment. We also have some other tests that we would think about from a functional end that are online neurocognitive testing, and then and then the quantitative EEG that I was saying before. So these are some of the tests that can be done. It’s also important, I think, for those of you listening that are concerned about your or your loved ones brain health, that if you do order, if your practitioner rather does order an MRI, there’s actually something called the neuro quant that can be added on to the MRI, which is a volumetric analysis of different brain structures, such as the hippocampus and ventricles and other structures that can actually tell you a little bit more about percentiles are basically the sizes of the volumes of these different brain structures. And that can imply that essentially what kind of what’s going on with with the brain as well. So those are some of the tests that that I recommend for a patient like Jose, and then practitioner. So I think one of the things with the family history dementia, and we always have to again, think of it as a team based approach, I would definitely recommend him seeing a neurologist is to kind of get the more conventional approach. And that perspective as well. We’d recommend him seeing a physical therapist, a functional nutritionist would make a lot of sense, and certainly a functional medicine practitioner that has specialization and brain health. So those are the people I would I would start with and depending on some of the findings of of the labs and testing that we do, we could refer to other people, but that would be a core. And I think a big core would also be a mental health therapist as well. A mental health practitioner therapist would be very helpful for a patient like Jose because you know, he does have depression, he does have changes in mood. And, you know, we also cannot overlook this as well. So, you know, it really does take a team, it does take a village here, the brain is very complex organ and the brain affects other organs and other organs affect the brain. So taking a comprehensive whole systems approach is really appropriate, especially for people with brain health issues like Jose, we hope that this episode was helpful for you. And just take some deep breaths now and please nourish your brain a bit here. And the meantime we will see you on the next episode which which will be on heart health, and I look forward to seeing you there. Thanks so much. Thank you so much for joining us today for this episode of capital Integrative Health podcast. A quick reminder that the information we share on this podcast is meant for educational and informational purposes only. It’s not a substitute for professional medical advice, diagnosis or treatment. We highly recommend that you speak to a qualified health care provider before making any medical or healthcare decisions. 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