Dr. Joe Tatta: Dr. Menolascino, welcome to the Healing Pain Summit 2.0. So everyone on this summit is talking about brain health and the importance of the brain as far as pain goes. So as our baby boomer population ages, I think dementia is on everyone’s mind. Absolutely, no pun intended, but can you describe what dementia is and why we should be concerned about it?
Dr. Menoloscino: Well, there are multiple different levels of dementia. We commonly call all of Alzheimer’s dementia, but there are different areas of medicine where it can occur in Parkinson’s disease and a special and called Lewy body disease. Some people have multiple small strokes that have a step-down decline to dementia, but really it’s a memory issue at the core and it’s a failure of the brain processing and it’s an inflammation process on the brain is how I see it. The commonality in all of those diseases really is the inflammation activated immune system of the brain. And that’s where I think the tie in chronic pain really lies in the combination of those two things being gas on the fire.
Dr. Joe Tatta: Interesting. So you talked about the immune system, which we’re going to come back to in a minute, but I think when we, when people talk about Alzheimer’s disease, they always wonder, is Alzheimer’s different from dementia and is there a difference or is it, can we qualify that difference?
Dr. Menoloscino: No. Dementia is really a clinical condition, whereas Alzheimer’s is a disease. The only way you can truly diagnose Alzheimer’s is post-mortem after someone’s passed away on a brain biopsy. What’s interesting is up to a third of the people that were diagnosed with Alzheimer’s on pathology, autopsy actually did not have Alzheimer’s. It was a different type of dementia. So it’s, it’s again, there’s multiple paths to the end result that we call dementia or memory loss in our, um, in our medical jargon. But the Alzheimer’s is one of the stereotypic classic types of dementia that we seem to lump a lot of it into.
Dr. Joe Tatta: And the Alzheimer’s that you’re seeing in practice and that we’re obviously experiencing, you know, in our nation and globally, is it that we’re getting better at diagnosing it or is it actually becoming more of an epidemic? I think
Dr. Menoloscino: both. Joe, um, we really call it mild cognitive impairment or MCI. That’s kind of the beginning of the dementia cascade and that’s what we’re seeing most of what we’re trying to intervene in this area where there’s some cognitive impairment and we can catch it. There are paper tests that are simple to administer, but they’re not very good. There’s full neuropsychological testing, which is very rigorous, needs to be done by a neuropsychologist expert, takes a full day, sometimes even into two days. And uh, there’s also some electronic software called CNS. Vital signs is what we use in our practice. It’s a 40 minute cognitive assessment that’s been validated. It’s very thorough and it’s a great way follow people over time.
Dr. Joe Tatta: Yeah. Interesting. So you talked about the immune system. If you brought it up early on in the conversation, I think it’s important to kind of touch on that. Um, when people think of inflammation and the immune system, I think of swelling or joint swelling, but how does that relate to our brain? Does our brain swell? What’s exactly going on in there?
Dr. Menoloscino: Well, you know, when I was in medical school, the brain was a black box. We thought it was untouchable and didn’t have any interaction with the immune system. Now we know that it has its own immune system and that it, it communicates with the rest of our immune system intimately. And that’s where I think the pain process really lies is that there are certain chemicals activated in chronic pain syndromes that activate certain pathways that interact with the neuro immune pathways of the brain. The cells of the brain are called the microglia and they’re very small kind of command or cells, the immune system. And what we’re finding is that a study that I know 30 years ago now showed identical twin women genetically identical. The one that took anti-inflammatories versus one that didn’t. The one that took the time inflammatories had a market reduction in Alzheimer’s and that was on proven on autopsy.
Dr. Menoloscino: So we thought maybe that was the key is to take anti-inflammatories. Well, we know it’s not that simple, but we do know there’s an immune activation that goes on and we’re looking at more nutritional ways to support the system. To reduce that inflammation and a calm that down. The other interesting fact is that there seems to be a parabola benefit that a little, a little immune surveillance is bad and too much immune activation. Inflammation is bad as well, whereas there’s a sweet spot where the the Seesaw of inflammation can protect the brain but not over activate the inflammatory cascade.
Dr. Joe Tatta: Interesting. So in my mind, I’d like to know what age this inflammation or this inflammatory cascade begins to happen. People so they can start to have an idea of you know, how far ahead of time they have to plan for it.
Dr. Menoloscino: Well, there’s two types of Alzheimer’s and we’re going to make it easier. We’re going to call all of these different dementias, Alzheimer’s, but there’s two different types when it occurs in the early fifties and then when they occur occurs later in the 70s and the early onset is much more aggressive and people pass away within two to three years. Whereas the late onset is much slower, cascade, much slower process. They seem to be genetically different because there’s a familial relationship to the early onset that you don’t get into late onset, but there seems to be a multifactorial cascade of effects and it gets down to this whole epigenetic idea is that it depends on what you do to your genes, not necessarily the card or the book of life that you’re dealt. It’s how you bathed information with your lifestyle, with the nutrition, with the lack of toxicity on those genes to activate them. So it’s really a combination and I think this process begins in your thirties and early forties it’s really what’s happening then that sets the stage because our brains are beautiful things and it takes quite a bit of damage before it manifests in a clinical way where you actually notice that there’s memory issues changing.
Dr. Joe Tatta: So what are some of the mistakes that people make regarding the nutritionist for as inflammation goes?
Dr. Menoloscino: Well, I think alcohol is a great easy place to start. We don’t really know. The government says two glasses for men a day is okay, that may be too much. I think alcohol actually erodes the wiring of the heart and the brain. So there may be a sweet spot. I also see a glass of wine as a glass of sugar. And it’s really this sugar load that seems to cause the insulin resistance that may be really fueling the fire. Insulin is the most inflammatory molecule your body makes. And so if you’re having bread, that’s basically a slice, a slice of bread is a glass of sugar, a glass of wine is a glass of sugar. You’re really driving this. And we’re, we’re actually calling Alzheimer’s type three diabetes because it may be this immune, uh, insulin driven growth factor release that drives this whole process that leads to these so-called plaques and tangles.
Dr. Menoloscino: That’s the, the pathology that we see when we do this. So I think all of that’s related and, and really it’s, um, a combination to me of the nutrition you put in and it’s also the toxicity you’re exposed to. I think those combine in a synergistic way where one plus one equals 10. And that’s really where I think we’re seeing this epidemic is that it’s a more toxic world. We’re using more medications, which to me, medications have toxic profiles, our environments more toxic and our food’s more toxic or the chemicals we use in our body. And so it really seems to be a perfect storm of synergy to make this occur more often at a younger age.
Dr. Joe Tatta: So you mentioned insulin resistance and I think it’s fascinating. So I think people are familiar with the word prediabetic and obviously diabetic, but in some businesses it’s something that you know, a lot of physicians don’t really test for. So just talking about some of the tests that people should look at, what kind of tests should they ask their physician for? Or a functional medicine physician position.
Dr. Menoloscino: So it’s, it’s one of the most unpleasant tests that they do where you come in fasting. And most doctors make the mistake of just checking fasting glucose or fasting sugar. But you want to follow the insulin curve as you do the sugar curve. So you come in and you get a fasting blood sugar, a fasting insulin, you drink a 70 gram nasty orange liquid and they test your blood sugar and insulin every 30 minutes for two hours. It’s called the glucose tolerance test. Well, in my clinic here in Jackson hole, I call it the muffin test. We have you come in, you could get a fasting blood sugar going to fasting insulin. We send you to the bagel shop down the street, eat their biggest sugar Laden muffin that they have. You come back 45 minutes later. And what’s interesting Joe, a lot of times we’ll see the sugar or glucose not have much of an increase, but the insulin has an incredible increase and that gets missed if you’re just following fasting blood sugars or the hemoglobin A1C, which is a standard blood test for diabetes.
Dr. Menoloscino: So I think that that glucose tolerance test is a great, a great way to do it. And I like my kind of modified muffin. It’s just easier on the patients and it’s just as accurate in our hands. Yeah, and I guess the question is how many years ahead of time does incident resistance develop versus it’s showing up as prediabetes or an actually diabetes? I think a lot of it has to do with your, your body shape and if you are overweight and as I tell my patients, we have a scale here that looks at their outside fat but also their visceral fat or the internal fat and you know it’s interesting we’re having an epidemic deliberate disease and it’s not hepatitis C, it’s fatty liver, it’s nonalcoholic fatty liver and that’s one of the hallmarks of the insulin resistance is I tell my patients, none of us like fat on the outside.
Dr. Menoloscino: As a doctor who cares about you? It’s the fat on the inside that really scares me. I call that the hot fat. That’s the inflammatory fat. That’s the fat that’s going to drive all of these processes. We’re talking about eventually leading to brain inflammation as well. So if your liver is not detoxifying, it’s not filtering, it’s not working correctly. There’s a link. Is there a link there with inflammation? There is. I think the link is the gut because a lot of things that we have to process, there’s a special circulation that goes between the digestive tract and the liver and certain chemicals. We’ll go back and forth multiple times until the liver finally is able to process it in a mechanism that lets you get it out of the body. That’s called the in-utero for gut hepatic for liver circulation and a lot of things, particularly hormones will go back and forth and there’s a way to assess whether that’s happening very well in medicine.
Dr. Menoloscino: As an internal medicine specialist, we don’t worry about the liver until the liver tests are three or four times normal. I want your liver test to be in the teens. I want to see him at 14 and 15 not at 25 or 30 which is still normal, but to me that’s a sign of an impaired detoxification, and there’s a test called GGT, which might be the best sign of toxicity in all of our classic lab standards. So ask your doctor for that one. If that one’s elevated, take a look around because there’s something that your body’s being challenged with. They call these things persistent organic pollutants or we call them pops and these are certain chemicals that our environment that are triggering this whole diabetic cascade, particularly this insulin resistance, and that may be at the heart of why we’re seeing this dementia increase. Interesting.
Dr. Menoloscino: So I think along that cascade, after the diabetes, we start to look at heart disease. What is the link between heart disease, the brain, Alzheimer’s, and our chronic pain that we’re experiencing? That’s a great question. One of the most interesting links is between chronic pain, which I see is stress. If you’re a person that’s in chronic pain, you wake up every single day in fight or flight, you have no idea what your pain is going to do to you to that day. And my heart goes off to those people. We really need to do a better job. That’s why I think you’re somebody who is so well time. Joe, I love the way you think about chronic pain and how you look at these chronic pain patients as people, as individuals. And really personalize their care plan. What we know is that if you’re under chronic stress, you release altered amounts of cortisol.
Dr. Menoloscino: We know the chemical cortisol is directly toxic to the part of the brain called the hippocampus, which is our memory for me, part of the brain. So we have a direct link between pain, stress, cortisol and brain health or brain brain disease, brain death. It’s killing the brain cells in that critical critical memory for an area of the brain called the hippocampus. We also know that if you’re in that fight or flight mode of chronic pain, the cortisol issues affect the immune system through a chemical called IGA or secretory IGA, which is a chemical that’s in your digestive track and protects you from the environment. We all have a two that goes through us and it gets exposed to the environment and you need to have that immune system of the gut supercharged to help you protect against all those things that you’re exposed to in our environment, in our water, in, in the medications that we take.
Dr. Menoloscino: So there’s a direct relationship between chronic pain, stress, cortisol, gut and brain health. And the relationship of those two. I tell a lot of my patients, we think serotonin controls mood, but where’s all the serotonin? Your body, because it’s not up here, 90% of it’s in your digestive track. So there’s a real intimate relationship between getting cortisol, stress, digestion, the brain, and the inflammation markers that the gut produces do end up in the brain. And the brain markers do end up in the gut. They’re completely related. Interestingly, Joe work, we’re calling depression, also an inflammatory disorder, and there’s a hypothesis called the cytokine hypothesis. Cytokines are chemicals that the immune system uses to communicate with each other, and there’s an activation of these inflammatory chemicals in depression and anxiety and in dementia. And it may be, again, one of those sweet spots where we need a little bit to protect us, but, but too much, too much is toxic and an overactivity is this as bad as having none.
Dr. Menoloscino: So it’s really trying to figure out for each person where on the cascade do you do best and how do we synergistically get therapies that one plus one can equal five. And I think that’s really where we’re seeing things like chronic pay, like dementia, like digestive health, like autoimmune disease come together in the functional medicine model because functional medicine looks at these different systems, not these individual symptoms. It’s a personalized precision way to help people and that’s what they want and what they need. Are there tests? We can have tests, exams, we can have to look up cytokine levels and different inflammatory factors that we should be aware of. There are tests where you can look at cytokine levels. Cytokines are very finicky so you can get led down the wrong direction. With cytokine testing, it’s quite expensive as well. A very simple test is called a C reactive protein or CRP and even the high sensitive CRP.
Dr. Menoloscino: For me, that’s just a nice easy way to say, are you inflamed or not? There’s advanced digestive analysises. What’s I’m sure someone on your summit we’ll talk about where you can really look at the digestion, the absorption, the inflammation microbiome, and see what each person’s individualized pattern is and then learn how to manipulate it and adjust it. For example, prebiotics, you think we need billions and billions of units of pre, pre probiotics to fill up our gut with more bacteria? Well, there’s 10 times more bacteria in our gut than there is human cells in our body. You’re not really changing the amount of bacteria in your gut. You’re giving new information to the gut to change the signaling that they do with different foods and different chemicals. So it’s an interesting way to look at the digestion beyond just doing a digestive analysis or looking for Giardia, but looking for these patterns of the microbiome patterns of malabsorption and also see if there are some bad characters that are there, some baggies or bad bacteria or some hope, some parasites.
Dr. Menoloscino: I’m also a big fan in food sensitivity testing. There’s multiple companies that do it. Some are better than others, and what it really does, it gets us access into a personalized nutrition plan for someone. What foods are inflammatory for you? What foods aren’t? Basically, it’s the dairy, casein and whey and the gluten products, the grain products. Those are 90% of the inflammatory foods we see. And it can be a game changer when we see people use those and start to dial down their nutrition and start to call them the fire in the gut. The fire ever else seems to calm down. The chronic pain comes down or arthritis comes down, their sleep gets better, their mood improves and their memory improves. So you talked about taking a couple of things out and I’ve seen gluten, dairy way. Um, those are all proteins that we can become very sensitive to.
Dr. Menoloscino: What, what kind of nutrients should be added? What kind of supplements are supportive for brain health? Well, you know, uh, it’s easy to over supplement and so with supplements there’s two really major points. One is the quality. I think there’s kind of grocery store level, health food store level, then medical or pharmaceutical professional grade and take as little supplements as you need, but take the best ones you can find. Omega three fish oil is a great example. A lot of people take the inexpensive, um, big box store official cause it’s cheap but it’s pre rancid. Even before they take it, they’re actually giving themselves more oxidative stress and building the fire than they are quenching the fire. So there’s certain supplements that’s crucial. You get high quality, I kinda call it the big five. I think most people benefit from a multivitamin with minerals. Most people do benefit from a probiotic and there’s some data that it may reduce your risk of the flu and other viral infections.
Dr. Menoloscino: Most people are low in vitamin D and the lab say of vitamin D level of 30 is adequate. We like it at 60 to 70 and I think most people benefit from some type of anti-inflammatory medical food or smoothie. That’s something that I get all my patients to start on to start to calm that fire down so that one of their meals is a very low inflammation, high nutrient packed, a high quality protein absorbable meal that I know they get started the right way. And that’s one of the things we start all of our patients on is just really help them get their nutrition set. And you know, really Joe, I don’t care what condition you come into my clinic with. If we do those things on the front end, we get about 80% of the benefit that then lets us focus on the really hard stuff and the things that we need to really do more advanced testing for and do more advanced analysis. So a lot of the easy work you can kind of do on the front end.
Dr. Joe Tatta: Yeah, that’s really interesting. So you mentioned the vitamin D and there’s, you know, vitamin D, there’s some really, really good studies on it. We got regarding headaches, migraines, back pain, neck pain, especially with spinal pain. What’s she, what’s the typical dose that you recommend for people?
Dr. Menoloscino: Well, there’s four vitamins that are fat Cybil, which means they can hyper accumulate in your body and you’ve gotta be a little careful with the dosing. That’s vitamin a, vitamin D, vitamin E and vitamin K. I’ve never seen a clinical toxicity from vitamin D, but anything over a hundred makes me concern. So typically we’ll start someone on vitamin D and we’ll check them in six to eight weeks just to be sure they’re not over accumulated. And people who are obese or people with liver dysfunction are the ones you really worry about getting toxic and vitamin D. so usually, um, I live in Jackson hole or climates, markedly different in the winter versus the summer. Typical doses are 5,000 units in the winter, two to 3000 units in the summer. I’ve never really seen him. I get in trouble with that.
Dr. Joe Tatta: Excellent. So you go to some really good take homes today on chronic pain, the brain and Alzheimer’s. Can you tell people where they can find you?
Dr. Menoloscino: I’m in Jackson hole, Wyoming. Our clinic is the medical clinic center for advanced medicine. Our website is www.men no clinic men. Oh, clinic.com and we have a bunch of great information on, there are blogs on there. There’s some quizzes to take to assess your health and we’d love to see out here in Jackson hole.
Dr. Joe Tatta: Great. I want to thank Dr. Menoloscino for being on the Healing Pain Summit this year to share information about brain health, dementia, heart disease, and chronic pain. Check them out meadowclinic.com make sure to share this interview with your friends and family so you can press the button on Facebook and Twitter to share it out and we’ll see you on the next interview on the Healing Pain Summit.
Dr. Menoloscino: Thank you, Joe.