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Inside Precision Medicine: What the EVANTHEA Trial Reveals About Brain Health

Dr. Heather Sandison, ND (00:01.263)
Welcome back to the Think Well, Age Well podcast. I am your host, Dr. Heather Sandison. And today I have the pleasure of introducing you to Dr. Craig Taneo. He’s a physician whose work sits at the intersection of internal medicine, brain health, longevity, and precision medicine. So I reached out to Dr. Taneo as kind of a fangirl. He comes very highly recommended by Dr. Bredesen. Dr. Bredesen speaks of him and the results he’s getting in his clinic in Florida.

often. And so, you know, I am often on those calls with Dr. Bredesen and he’s bringing up these amazing results Craig is getting in Florida and you should talk to him. And so finally, we have the opportunity to talk shop here on this podcast and have you, our listeners, listen in. I’m excited to learn from him. He is the co-founder of Resolier Health, where he leads a clinical team caring for patients with chronic complex conditions.

often these conditions that are poorly addressed through conventional medicine. His work includes supporting people with cognitive decline, course, neurodegenerative disease, but also chronic fatigue syndrome, long COVID, environmentally acquired illnesses, autoimmune conditions, and of course, he’s focused on healthy aging. His focus is also on root causes, like us always, practical options and patient-centered care. He’s trained at UCLA, UCSF,

Penn and Wharton, and he’s held major leadership roles across medicine and healthcare systems. He’s even served as the chairman of Maryland’s Healthcare Commission and chief medical officer of Gencare Senior Medical Center to partner at McKenzie’s Healthcare Practice. I mean, you have worked in so many different places when I was, I’ve been chatting with you. It’s like you really do integrate. You have this perspective of where insurance,

and the practical implications of what pairs need and what patients need, where all of that comes together. And I think you and I both share this deep desire to make sure that patients who are suffering with dementia, with Lyme disease, with chronic fatigue, where they fall through the cracks typically in those insurance-based systems, how can we get them what they need?

Dr. Heather Sandison, ND (02:18.511)
Dr. Taneo is also a co-investigator in the EVENTHEA trial that has been led by Dr. Dale Bredesen, exploring the effects of precision medicine on reversing cognitive decline. And he’s a principal investigator in active registry studies examining real-world outcomes in patients with cognitive decline. So Dr. Taneo, I think everybody gets why I’m so excited to talk to you today. Welcome, I’m so glad you’re here.

Craig Tanio (02:44.578)
Thank you, Heather. Thanks for that kind introduction. And I think we really do both share this intrinsic desire to get health care to work for our patients. And there are just so many systemic barriers that need to be removed. But when they can be removed, the results are really magical and impressive. And so sometimes it has to be done at the individual level. But hopefully, as we all work together collaboratively,

we can start to accelerate the change so that many more people can get access to this type of care.

Dr. Heather Sandison, ND (03:21.041)
Well, it’s a super exciting time because we have data, right, that can start to drive that shift in what gets covered by insurance. And, you know, whether the powers that be, how we have to present it and the hoops we have to jump through, that is still to be determined. But I think it still is this really exciting time where we can point to some of the data and say, hey, look, like this has the potential to not only reduce suffering, but reduce costs, societal level costs.

I want to start because speaking of this data, you have been very involved in collecting some of it recently. Can you catch us up on where things stand with the Evanthea trial and why you think this is such an important part of that broader conversation about how we approach cognitive decline?

Craig Tanio (04:07.116)
Yes, so think the Evanthea trial, I think is going to be really looked at as a historical landmark in the care of patients with cognitive impairment, because it is really the first randomized clinical trial of a comprehensive precision medicine approach to care. And as you know, Dale (Bredesen) has been discussing this approach to precision medicine the whole time, but it’s been a challenge to

the funding to actually do the trial. And so where we are right now is that the trial has been in pre-print and that pre-print is available for everybody and it is in the process of peer review right now. And so hopefully it will get through peer review rapidly and we’ll be out in a final publication, you know, perhaps at the end of spring or early summer. But I think we can talk about the trial in a couple of ways.

You know, I think the first is that it was, there was a control group. And so there was a group about one out of every three patients got the standard of care. What was the standard of care? Well, you look at up to date or you look at the neurology guidelines and say, we’ll make sure that those patients get that level of testing and then they will get what the guidelines have said. And so that,

was clearly an issue. So you want to recruit people who are excited about doing the work. And so they needed to have a partner with them to do the work.

And then you have to say, well, one out of three people, you have to wait for nine months and do nothing or just do what the standard of care is, which is essentially nothing. And then and not cheat during that time. So that’s always a challenge in these studies. Almost always, historically, the studies, the control group does get better. I think in our in our study, the control group got slightly worse and sort of in parallel with historical cohorts. And that’s, think, because we did take

Craig Tanio (06:19.648)
a lot of time to talk to people and get them to be aligned with what what was what we were trying to do. And then those people who were in the control group, or the standard of care group got the precision medicine approach after nine months. And then the other group got the precision medicine approach. And at a high level, what I would say is people should know the following. The study worked.

period, end of story. And then the size of the effect at a high level.

pretty similar, if not greater than what was done in the pilot. So when you put the control group together, you saw the similar type of an effect that was happened a couple of years ago, which is already two really important things. know, John Ionitis, who studies this at Stanford’s would say, probably 70 % of medical interventions never get a good corroborating second study. And this got a different study.

the investigators, there were two investigators who were part of the original pilot study, and now there were four additional investigators who came in. So now you’ve kind of stress tested this in two different dimensions. And so we call it an approach rather than a protocol, because I think that there are some important decisions

that happened in the creation of the trial. The piece around lifestyle, which was pretty standardized. So it’s a number of the dimensions which you’ve talked about and what Dale has talked about and others, getting exactly diet right, getting into ketosis, getting movement and exercise exactly right, stress management, the right sleep, the right level of brain exercises, all of those things were very standardized.

Craig Tanio (08:25.764)
There was a standard list of labs that were looked at and to investigate to look for root causes. So things like the Genova Nutrival and the GI effects and testing for toxicants. All of those were very standardized, but the investigators were allowed to use their judgment.

because actually aligning on a protocol, as you know, that could be very controversial around that. And I think there were choices made, that there was variability. And then in some sites, there was some heterogeneity in doing what I’m happy to talk about further, which we call intensive neuromodulatory therapy, things that can really help the brain accelerate healing,

including hyperbarics and photobiomodulation or laser light therapy and neurofeedback. And if we can kind of put these together guided by the QEG, how does that actually look like? But it’s a precision medicine approach. And so when you think about trials, usually trials are very cookie cutter. If A, then you’re doing B. But if biology is such that things need to be personalized,

How are we going to really learn about this going forward if there’s judgment involved? And I think it’s going to tax a lot of the methodologies of doing trials going forward. We’re very used to doing trials where there’s one intervention being done.

But if the biology of cognitive decline is such that one intervention is not sufficient, or that to heal the brain, you need to heal the body and the brain with multiple interventions, then it’s going to be a methodologic challenge. And that’s, think, what’s been the real biggest barrier here is that the science of doing these trials has needed to evolve. And I think we’ll need to further evolve with this.

Dr. Heather Sandison, ND (10:17.253)
Right.

Craig Tanio (10:35.376)
So, you know.

Dr. Heather Sandison, ND (10:35.392)
Yeah, this is that concept that medicine at this stage is driven by this idea that a single molecule intervention, we need to limit all the variables except for one. The single molecule intervention that…

Unfortunately, there’s these perverse incentives, right? Because it’s a single molecule, because that’s something that can be patented. Now the drug companies have an incentive to do these very expensive trials. And yet, when we look at dementia and Alzheimer’s, any neurodegenerative process, there’s not usually a single molecule that’s going to have an impact.

And so the challenge becomes how do you create a robust trial that answers this question or seeks to understand around this question of does this intervention have a positive or negative impact or any impact at all, right? A null hypothesis, if you will. And how do we design something that has a level of complexity that matches the complexity of the disease, right? The intervention needs to address the root causes. It needs to address the causes. And if a single molecule is what’s easy to step

that’s what gets studied even though that might not be the solution. It doesn’t really make sense for that to be the solution, right? Am I, like does that explain it in kind of other words?

Craig Tanio (11:53.164)
Yeah, no, I think that’s, I mean, that is really the essence of this. I mean, if you have a system, you know, and Dale has talked about that multiple times where you can affect one root cause, two root causes, three root causes, you don’t seem to get any change clinically. And then four, five, and six, you start to see that tipping point. And the challenge has been clinically is can you predict that ahead of time accurately? No, you can use clinical judgment, which means if you listen to your experience,

and other people’s experience, you get a sense of a sequence and a hierarchy of interventions, which is really important. For example, we’ll always try to put some of the good things and hormones and nutrition and things that would have very little adverse side effects and put those things first before touching anything that could have bad side effects like detox or aggressively treating chronic infections too quickly.

you know, those are, you know, so there’s a sequence there, but, you know, in really getting the right structure, that’s, that’s, that’s tricky, because I think you could, you could see the criticism of the study that it would be, well, you haven’t figured out exactly what the combination is for everybody. But I think the answer would be, we have a combination that’s worked for 90 % plus of people.

in the trial and it’s a combination that looks quite significant. So why wouldn’t logical people put more research into this? And then even if, yeah, go ahead.

Dr. Heather Sandison, ND (13:34.832)
especially when the disease can be so torturous. It’s just so expensive, so emotionally taxing, so physically taxing, not just for the patient, but for everyone who loves them. So it’s such an expensive disease. we have directionality in terms of what could help solve it, why not run in that direction?

Craig Tanio (13:56.258)
Yeah.

And I think that what we have to do is the moniker of evidence-based medicine. That was something that I studied very in depth in the late 80s and early 90s as a general medicine fellow. And at that point, evidence-based medicine, I think, had a little bit purer motives. It was just, let’s put some structure in science and make sure that’s guiding clinical practice. And really what happened, it got hijacked by

government regulatory bodies and insurance coverage and it was used to drive coverage. But in evidence-based there was always the notion of a clinical judgment and there was always the notion that you could do N of 1 studies to figure out if a patient did respond and if so that was if it was done in a reasonably rigorous manner that was good quality evidence. And so it didn’t not everything needed to go through a randomized

clinical trial. So you could imagine in the future if we did registries and I think one of the key outcomes of any of this research is going to be what’s only been addressed in one of Dale’s papers by looking at individual cases. But if you imagine that we could get, you know,

10 or 15 practices together, and we all do a registry and we say we’re committed to enrolling 100 % of people in there. And five years later, you say, in the real world, what’s happened is we’ve slowed down decline and I’m just making it up, know, two thirds of the people and they didn’t decline. If you ran that through an economic model,

Craig Tanio (15:42.926)
hypothesis is it would save the healthcare system money because of the savings of nursing home and caregivers and all of that. And the open question is how early do you need to intervene to get that stopping of decline? And that’s where the research should go. So some of this could really be real world medicine. And really what’s happening is that the cost of AI and data collection is just dropping and plummeting by 80 % year over year.

we should be able to do this with enough creativity and will. And the healthcare system should be excited about doing it because there are not too many areas where you can actually save money.

the health economist would tell you, if you can find something that saves the healthcare system, that’s a 1 % event. It’s not, the politicians will talk like it’s all around us that we can save money, but I do believe that influencing cognitive impairment can save the healthcare system real money.

Dr. Heather Sandison, ND (16:49.016)
And really society at large, right, because people can stay in the workforce and there’s so many ways, there’s so the tentacles of this just reach very, very deep when we’re talking about cognitive impairment and how many people it affects in that ecosystem.

Craig Tanio (17:05.635)
no, without a doubt. mean, I put my economist hat on, really, you know, when as people get older.

there’s, you people want to have quality of life and quality of life is driven by, you know, brain health, which affects your cognitive and your emotional health, and then, and then your physical health. And, and everybody is scared that their cognitive health is going to go down, which is still the major barrier in people coming to see clinicians like you and I, because they are still worried that they’re going to get a bad, you know, prognosis and not be

Dr. Heather Sandison, ND (17:15.95)
Yeah.

Craig Tanio (17:42.594)
able to do anything.

Dr. Heather Sandison, ND (17:44.057)
Yeah, or have their driver’s license taken away and then their independence and now they can’t get to church and to the senior center and to the grocery store. Yeah, there’s so many tangible repercussions of this. You have seen patients, on a hopeful note, you have seen patients make really significant changes in cognitive outcomes. I’m curious if you have any patient stories that you’d like to share and especially if there’s shared characteristics or patterns.

that you see amongst those who get the best outcomes.

Craig Tanio (18:17.206)
Yeah, so I happen to just watch your discussion around is it too late the earlier this week, which I loved, you know, about the five factors, especially around the belief factor and the timing and the timing windows. I think that, let me answer that question, but let me like set it up. I think in doing the study,

It was an amazing learning journey for us as for myself and our team because we got a chance to really collaborate with other centers and just say, what is the best practice? So I’ll give an example. I think we try to be driven by outcomes and just look at the data and don’t try to throw too many emotions around it. And I think we were able to get maybe 65

70 % of patients into ketosis in the first month, you know, before we did the study, but all of the dieticians came together and they shared their best practices and hacks and they and that was part of the preparation and they probably all talked together for a good four or five months putting together the protocols. And I will tell you in the study, first four weeks, 100 % of our patients got into ketosis, I was like, wow, that’s really great. You know, and yeah, exactly. It is it is it

Dr. Heather Sandison, ND (19:40.405)
This is doable. We can do this. Yeah, when you share best practices.

Craig Tanio (19:46.528)
it is doable. Exactly. It doesn’t matter who had the best practice. Let’s just share it. And let’s, you know, let’s develop it. Like we always say internally, we don’t need to be the best. We just want to be in the top tier. There’s no, there should be no notion of the best when it comes to healthcare. Everybody should get top tier care. But the second thing is, that, you know,

My background has been I’ve always worked with underserved populations. I ran federally qualified community health centers and the Medicare Advantage practice was for people in the inner city who didn’t have as much care. And so we tried deliberately to recruit a set of populations that usually could not afford this type of care. And so they got a dose of just the coaching and the handholding and exercise

training and that which they were.

could not have gotten and it was just very gratifying to see the response in people and for me has given me the drive to try to get better coverage because this should not, the only reason that we have cash practices is to have medical freedom at this point. And then the second half of the study, our clinic did a lot better than the first half,

to me says there’s a learning effect. There’s a lot of data management and even though we have been practicing precision medicine for about 10 years now, is that there’s still a lot more that we can do to up our game. So it’s an approach, it’s a skill. I think if we all get together, we can all up our game and that can really help patients.

Craig Tanio (21:42.146)
What we have learned over time is that

you have to kind of match the interventions to the severity of the condition. It’s that window that you talk about, the timing window. So if somebody has subjective cognitive impairment, for the most part, I think a health coach who works around all of the life essentials is gonna be perfect. And you’ll get a lot of good change and that won’t be an issue.

Dr. Heather Sandison, ND (22:08.976)
Yeah.

Craig Tanio (22:16.976)
think the things that we see clinically is the belief factor can come into play where if somebody has infections and toxicants.

Dr. Heather Sandison, ND (22:30.032)
Mm-hmm.

Craig Tanio (22:30.868)
and they’ve been working on trying to optimize everything, but they haven’t measured those and they don’t know about those and they get frustrated, then their mental model is saying, this isn’t working when the actual answer is we haven’t opened up the full aperture to see what all other root causes are. And unfortunately, you know, a lot of the chronic infections and toxicants that we’re dealing with

are not our fault. I mean, so I’m in South Florida. can’t, you our…

Dr. Heather Sandison, ND (23:03.322)
Okay.

Craig Tanio (23:08.648)
you know, our residents can’t help if they’re dropping pesticides to from the air to, you know, kill mosquitoes. That’s just a that’s that’s in the matter of public health. You know, I think there’s a lot of of toxicant issues that are much more in the regulatory side than in the individual behavior side. And I’ve seen a lot of patients beat themselves up for, you know, for toxicant issues. And, and that and that’s, I think, a bit misguided.

Dr. Heather Sandison, ND (23:15.691)
and

Craig Tanio (23:38.464)
But think the infections and toxicants are, I think, always the most challenging things to deal with, if you will. And in the study, I think we saw a set of people potentially take a step back where sometimes the driver was that we were detoxing too quick. And so we have to be careful about that.

And then what we’ve learned in the clinical practice is atrophy is an important issue to understand. So on the MRI, when you can see generalized atrophy or focal atrophy.

that can be a negative prognostic factor, but you don’t always know with the MRI, are there injured cells or are there dead cells? And so we’ve used the EEG over time to look at that. And that’s really been helpful because what we’ve been able to do is when there’s been atrophy, we can oftentimes see within weeks that the cells are responding to the right therapy and you would never be able to see it on MRI.

because MRI changes usually take 12 to 18 months, but the beauty of doing the EEG is that you can see those at the bedside. So it’s literally like having a stethoscope for the brain, and once you learn how to use it, you’d be like, why wouldn’t we use it for everybody? And we do.

Dr. Heather Sandison, ND (25:10.16)
Nice. Yeah. So precision medicine, we’ve talked about a couple of times. You’ve mentioned that term. Will you define that for people who are kind of newer to this space? And really if you can compare and contrast, like how that’s different from walking into a primary care provider or a conventional neurologist.

Craig Tanio (25:31.406)
It’s a great question. So I think precision medicine historically kind of had their roots in genomics and pharmacogenomics and oncology, which is let’s actually understand specifically some of the genetic variants and let’s get our drugs to be exactly to meet those particular variants, or it could guide specific chemo.

and we could do metabolomics. Let’s look at all the different metabolites or transcriptomics. Let’s look at all the messenger RNA. I think we have a much broader sense of precision medicine. And what I would tell your audience is…

I have a couple of very simple beliefs, but then it just kind of translates into a different way of practicing. I think that most chronic disease are caused by more than one factor.

So we can simplify it. It had been simplified with cardiac, know, with atherosclerosis to say, well, it’s lipids. But, you know, now that GOP ones are out, the cardiologists are having conferences about metabolic disease and atherosclerosis. But there’s, but but most people will look at this who are who are good scientists and say, yeah, there are multiple causes. But the practice of medicine hasn’t necessarily evolved to say if there are multiple causes,

Dr. Heather Sandison, ND (26:50.384)
Thank

Craig Tanio (27:05.328)
let’s actually treat those causes at the same time. And the beauty about doing lifestyle medicine as the foundation is so much of healing can be improved by just getting that foundation right. If you get clean food, clean living, that will make a huge difference. And then the precision part is understanding what are the pathways that are being identified

And then I think that there is a hierarchy and sequence to affecting those pathways. And importantly, there’s a way of recommending treatments that align with the patient’s values and judgment, resources, biases, and getting that to work exactly right. So you’re trying to get that personalized for the individual person. And it’s.

Dr. Heather Sandison, ND (28:01.882)
Even practicalities, right? Like I mentioned having your driver’s license taken away. If we start talking to a patient who doesn’t no longer has a driver’s license because it’s not safe to drive, they have access to different things than someone who, you know, is or even if somebody’s in a community or somebody’s living in a residential care community, a care home, a senior living community, very different practical implications for what type of treatment plan is going to suit them.

Craig Tanio (28:33.238)
No, that’s exactly right. It’s got to be personalized to the individual. But the challenge just becomes in here is that what I believe is that precision medicine, there can be a set of principles that guide how we practice. And then what’s going to happen year over year is so the how that we do this should stay the same. There should be enduring principles.

And then the what we do will evolve rapidly as the research and science progresses. I went to UCSF for medical school. I remember the very first day of med school, we were in the auditorium and they said, half of what you learn is wrong. You just don’t know what half. And that was such an important lesson, because it was a bit of humility about what you’re trying to develop as

as a clinician and as a healer, and to know that there’s limits of what your models are. And so especially here in precision medicine, I don’t think that we come in with any arrogance and say, we know exactly the answer here. But I think what we do know is we have a much better mouse trap than what’s been heretofore, and that patients shouldn’t have to wait to get some of this type of medicine.

Dr. Heather Sandison, ND (30:00.143)
Yeah, and I think…

Part of that is that the side effects of this intervention, although it can be expensive, so right cost is part of this. If you’re buying supplements and paying out of pocket for testing and for providers that are cash-based practices, this is expensive and that’s something to absolutely consider. But the other effects or side effects of it are that blood sugar normalizes. Often depression and anxiety calm down, sleep improves. We talked about atherosclerosis and often

cardiovascular risk goes down. We have patients whose incontinence resolves. So you see that there’s, generally speaking, patients who engage in this approach live healthier lives. And when that’s the side effect versus, you know, of course, brain bleeding, brain swelling, whatever.

the litany of potential risks with many of the pharmaceutical options, this becomes sort of an obvious choice, at least to have as an option.

Craig Tanio (31:03.074)
No, I think that’s right. And I think that the challenge has been something like this. For example, on the nutrition side, we know that the research around most nutritional studies that are driven by surveys is just not high quality, the things that sort of make it to the front page of the New York Times. so obviously, if you have Dean Ornish’s study that’s looking at

you know, low fat, and we’re looking now at this, they have a theotra, which is ketosis, and they’re both getting good results. How do you reconcile some of these issues in nutrition? And I think those would be a great head to head study. Because, you know, my hypothesis is both are so superior to the standard American diet, that it’s an upgrade. But the only way to figure that out is to really compare the two. And there may be subtypes

that respond to one versus the other. You just have to figure it out. But I think that the, let’s say the cultural bias in conventional medicine has been, I talked to, you know, medical students and residents still as sort of, you know, being on faculty at two places. And they think about nutrition as just being, okay, let’s just go get a, you know, healthy diet. And they don’t think that it can all be personalized.

to the individual. And if we really understand that food is medicine, I you can boil it down very simply to people and just say, don’t eat food, only foods that don’t have labels. That’s going to get you 80 % of the way there. But there’s a lot of individualization of diet that makes such a difference. so I think…

there’s a much better way to do precision medicine with food if we can do head-to-head studies. so folks like Terry Walls, I think, have been incredible at getting advances in there by just saying, we’re going to do good clinical trials around nutrition. so I do.

Dr. Heather Sandison, ND (33:16.964)
So my hypothesis, excuse me, my hypothesis around the kind of vegan diet versus the ketogenic diet, and I don’t think anyone should do vegan keto because I do think that’s too restrictive and you start to limit nutrients. And I think that probably what will play out in the science now, I don’t know, this hasn’t been done, but is that what’s best is to go back and forth, is to have some periods of ketosis and some periods that are plant-based.

and maybe doing that seasonally, but that the consistent thing about paleo diets or these ancestral diets was inconsistency. So it’s not that we should be eating the same thing for breakfast, lunch, and dinner day in, day out. It’s that we should.

change that with the seasons and maybe even change that within seasons of our life, right? And for premenopausal women, the right diet is probably different from a postmenopausal season that they’re in. And so I think when we think about diets, not only should we do the head-to-head trials, but just, think, an openness to variety and to changing up those diets, I think is food for thought anyways.

Craig Tanio (34:27.156)
No, I couldn’t agree with you more that the whole notion of cyclicality is critical. you know, over the time we’ve evolved some heuristics, which is, we want to get people to the tipping point so that they feel confident that their work is making a difference. And what’s the time frame? Well, hopefully six months or less, because that just kind of proves to be a practical approach.

approach and the study, I think the vast majority of people had made document improvement within the first one to three months, you know, so change can happen fairly quickly. But if you can get that improvement, then of course you can experiment with cyclicality. And I think you see the biggest pain point is oftentimes supplementation, you know, people are like, do I need to take this much? And the answer is, maybe not. But we’re gonna have to, you know, we’re gonna have to see and

and we work on that. And I think there’s a huge amount of cyclicality that makes a difference. We don’t detox every day of the week. Maximum is five days, but I think as people get older, we usually do it to four or three, because you just can’t handle that stress every day of the week. But it’s harder to explain, and it’s easier to write linear protocols.

Dr. Heather Sandison, ND (35:56.849)
Yeah, and certainly the piece around ketosis, because so much of this came up, this conversation came up after the Ornish trial was published in June of 2024. And really, my clinical experience is that there isn’t a lever more powerful that you can pull than getting into ketosis. Is that your experience too?

Craig Tanio (36:15.564)
I think, yeah, I think I’m a complete believer in the 80-20 rule, you know, that there’s a handful of things that make the majority of difference. And I think my clinical impression has here has been, you know, top two would be hormones and ketosis for women. You know, I think bioidenticals are stronger for women than for men, but those two are definitely the top two. I think circulation has really been the next big lever.

and I think something that can be underappreciated if you’re not always looking out for subtle signs of dysautonomia or microvascular issues, but it just makes sense that the brain needs oxygen, needs circulation, and may not be getting it.

Dr. Heather Sandison, ND (37:02.68)
Yeah, and I think I would put my two is the keto diet and sleep, treating sleep apnea, which maybe fits under your perfusion and circulation. I want to dive into these neuromodulatory therapies, and because you really are an expert in these things, so I want you to share with us, how do you decide precisely what works for who, who’s going to…

Craig Tanio (37:20.334)
Sorry. Yeah.

Dr. Heather Sandison, ND (37:31.288)
try on what, and if you would list them for us again and then just describe, you mentioned photobiomodulation, there’s hyperbaric oxygen therapy, you’re using a QEEG, neurofeedback, so take us through those, tell us who they’re a good fit for, and give us a little description of what they are.

Craig Tanio (37:50.819)
Yeah.

So I think that let’s just start with the QEG because I think what the QEG allows us to do is to measure the brain’s function. So you can do that with a PET scan or a functional MRI. And those are oftentimes what’s being done in the research. I think that QEGs had been invented by the psychologists. And so that actually delayed, I think, the adoption into MD.

driven medicine for about a decade or so, but now most of the QEG literature is really being in the radiology and the imaging community. It’s just seen as another imaging modality. But the benefit is that you can, in terms of, it measures brain’s electrical signals and the electrical signals work at different frequencies. So a slow frequency, for example, delta, we just call it like similar to delta sleep and deep sleep. The brain is

working at one to five cycles. then, you know, beta and high beta where a lot of the cognitive activity is, is usually, you know, 15 cycles a second to 30 cycles a second. And then there can be even gamma above 30 cycles a second. So we’re measuring brain wave frequencies, and we’re doing it through a cap, which has, you know, 19 channels. And we’re using very sophisticated software

so that we can actually localize where there are functional issues and the software will oftentimes give you the equivalent of an MRI that you can see. And then you can also see networks and those networks have really been plotted out. In the Obama administration, there was a very deep set of work guided by the NIH to look at a number of different networks ranging from, know, what are the major sort of memory networks or attention and that

Craig Tanio (39:51.072)
networks and such. And so, you know, for example, just in this last month, I had a patient who came in who had very little symptoms and thought it was just for prevention, but it was clear on the volumetric MRI that it looked like posterior cortical atrophy. But literally the CNS vitals were all in the 90s. Like she had no cognitive issues, but she felt something was not quite right.

And we could see on the QEG the very distinct pattern of communication that was going through the parietal lobe that was interrupted. And so that looks for things like coherence with the different networks. And so the important thing about the QEG is you have an objective measure that can change as you are trying to improve the brain.

And that objective measure can change as quickly as three to five days after doing an intervention. So we’ve kind of developed our, you know, I spent about two years getting trained by Dr. Bill Lambos, who I’m super appreciative for all the work that he did and time to mentor me to get board certified in this area. But, you know, once you start to use it, you’re like, well, this

this really just helps me decide what treatments work because it’s like being back in the hospital and seeing, you know, where some of the more sophisticated labs are. The downside for a patient is they might have to have a bad hair day. They get a little bit of gel in them and on there and then have to wash that out. The technology hasn’t evolved that the dry QEG caps are as precise. But really when you have a tool

that can measure change week by week, you suddenly then can start to be a little bit more precise with interventions. And so how this evolved before the study was hyperbaric oxygen. We like to follow the literature and we think that the Israeli researchers, Dr. Afrati and company have done the best research around hyperbarics because they created

Craig Tanio (42:18.032)
great placebo hyperbarics. They had people go into the multi-chambers and they to have sham hyperbarics, they cranked up the pressure for the first five minutes so everybody felt it in their ears and then they dropped it nearly to room atmosphere and instead of breathing oxygen, you’re breathing room air. So you now have for a procedure, really the gold standard, you have sham hyperbarics. And they’ve shown in a good four, five, six studies now that hyperbarics

does in the brain what it does in the body, which it just bless you, it, it, it treats wounds, it helps to heal wounds. And those are wounds that can be from traumatic brain injury, but it can also be from chronic infections, it can be from inflammation, it can be from toxicants. And so it is just helping the brain heal. And there was, you know, pretty solid data post COVID that that was an intervention that was that was helping. So what would happen

and in practicality is many of those protocols are 60 sessions, two atmospheres, 90 minutes, hyperbarics, unfortunately, isn’t covered by insurance for cognitive issues. It is in Israel. It’s gotten great coverage. And I think here, the insurance committees have said, well, that’s an Israeli study. We’re waiting for the US studies to happen, if you will.

Dr. Heather Sandison, ND (43:46.9)
And for consumers, do you mind if we just, I want to take a minute here to talk about the chambers, because I think it’s easy for people to go, oh, there’s a chiropractor down the street who’s got a hyperbaric chamber. He’s been telling me to get in there. But there’s a difference between, the Israeli study was done in hard chambers, like in a hospital, like grade where you can go down to two ATMs. Whereas

Craig Tanio (43:47.792)
Yeah?

Dr. Heather Sandison, ND (44:10.926)
the soft chambers, it’s not exactly the same thing. So I’m wondering your thoughts about sort of on this spectrum of hyperbaric therapy, do we expect the same results if we’re not getting to two ATMs and we’re not doing, because I think a lot of it is also some of the hypothesis around what they’re doing at Aviv clinics and in those trials was they’re going back and forth. It’s almost like a contrast, right? You’re getting in and you’re getting out. And they think that some of what’s happening is the going back and forth from

room air too concentrated and at pressure. So can you talk through some of that new one?

Craig Tanio (44:45.548)
Yes, so that it’s so what a VV had done is they looked at the hyper oxy hypoxia paradox, which is that the that the brain seems to resend and healing responds better when there can be an air break. So what it works is that you you you are breathing 100 % oxygen for 20 minutes, then you take off the mask for five minutes, and then you put the mask back on. And so I’ve always believed when it comes to protocol

you know, in medicine and in life, if you’re going to adopt something, you should just adopt 100 % of it to start with, you know? So I would see oftentimes in other situations, people would say, well, this protocol doesn’t work. And you’d say, well, what’d you do? And it’d be like, well, I did these four things and I changed these two things. It’s like, well, your interpretation of the protocol didn’t work, but you didn’t actually try the full protocol. So we went to,

to do a frotty when those protocols got published because we just felt that the evidence was better. We had been using 1.5 atmosphere hyperbarics, which was the soft chambers, and it was a higher cost to do the 2.0 atmospheres, but I felt the research was better. My clinical intuition, but it’s that you can get similar

affects, let’s say, with 1.5 atmospheres, but you have to do it for a longer period of time. And if there’s significant atrophy or damage, you may not be able to get the same effect as you would with the higher atmospheres. the FDA, when looking at…

hyperbarics when it came to the military in the early teens, they basically said, look, hyperbaric is a drug, there’s two dimensions, there’s pressure, and there’s oxygen, and they work completely separate. We think that the pressure actually changes gene expression so that the higher the pressure, all of the inflammatory genes are calmed down, and then obviously oxygen can be incredibly helpful,

Craig Tanio (47:08.272)
But for example, in our patients with chronic fatigue, oxygen, it can induce too much oxidative stress. And so we’ve often done hyperbaric chamber with no oxygen because it was too inflammatory in the beginning. with all of these therapies, you got to start from the research and then adjust. But I do think that for, let’s say, most patients with cognitive impairment, it would be better to get a two-atmospheric

treatment, all else being equal. But if finances are too much of a barrier to that, then I think 1.5 is better than none.

Dr. Heather Sandison, ND (47:50.646)
And what about EWAT, the exercising with oxygen therapy? Where do you put that on this spectrum?

Craig Tanio (47:57.826)
You know, so I’ve used it a lot with Parkinson’s.

because we really want our Parkinson’s patients to exercise as much as possible, because there’s such good data showing that the BDNF effects from exercise with Parkinson’s makes a huge difference. And you can see that oxygen just gives that extra burst for intensity that makes a difference. But I haven’t seen as much data around EWAT in the literature as there is on hyperbaric.

you know, our practice has gotten more anchored on hyperbarics. And, you know, this is one of those areas where I think we have to do more.

study and research, but it does kind of come out with some of the technology. What’s been very interesting is some of the two atmosphere chambers were never available at home until the last year or two, and now you have some of these that could be used at home. And so the open question is, if it’s safe,

and low cost and you’re in your 60s, is it better to just buy one and use one at home for the next 30 years? That’s an open question, if you will. And we’ve tried to work that out individually. There’s not any good literature on that. But if you think that hyperbaric heals wounds and a lot of aging prevention is just helping to heal wounds, mean, there’s certainly a biological plausible

Craig Tanio (49:38.457)
that it could be good for a long period of time.

Dr. Heather Sandison, ND (49:39.322)
Yeah.

Dr. Heather Sandison, ND (49:42.801)
Okay, this is really fun. I want to get into photobiomodulation before I let you go here. So let’s talk a little bit about red light therapy and how you use that. Get into the nitty gritty, the nanometers, is it hot? All the things that come up as you explain that to patients.

Craig Tanio (49:48.622)
Thank

Craig Tanio (50:01.154)
Yes, so what you can see with the, so you can see in the literature, first of all, that we use a class four laser with Aspen and.

and Dr. Bob Hedaya and others has been really instrumental in writing some of the initial case studies on response of patients to a higher intensity laser. But what it does look like is that the higher wavelengths do get through the skull and that power does make a difference. And what the higher wavelengths

do do at the cellular level, it does look like it gives the cell more energy. You know, I tell patients it’s a little bit if we can if we can target it in the right way, it’s like starting up a battery of a car, you know, but and so you can see that those cells are working and that there’s an improvement. But you have to help those cells metabolically if they’re going to continue to stay active. So it can be an adjunct.

but it is a very, you know, it’s a very complementary adjunct. Neurofeedback is done really as a biofeedback to improve some of the brainwave functions and we can look at the networks and we can basically teach people how to train their networks better. The timing of that is really important because if the cellular health isn’t there,

neurofeedback can be very frustrating. So what we did in the study is we waited till the last three months to do those therapies for people. And so we thought that the worked on lifestyle in the first couple months really address root causes through months three through six and got those down. And then the last three months would get the more intensive neuromodulatory therapy.

Craig Tanio (52:13.76)
How it works in practice, but we didn’t do that in the study is the addition of IVs. So there’s a lot of intravenous therapy that can really help. But again, it’s just guided by the notion of on a…

you know, in our clinic, what we do is on Monday mornings, we kind of look at the EEGs from Friday and say, did we make progress? you know what’s what’s happened? What are we going to do different? How are we going to adjust it? And you know, what people want to know many times when they’re coming in, in our in our practice is, you know, you looked at the data, just tell me the protocol. And and I say, you know, I wish it was that simple that and and we’re not at that

Dr. Heather Sandison, ND (52:57.839)
Okay.

Craig Tanio (53:00.352)
level yet. We can understand safety of these individual things. We can understand the typical response, but we have to understand how that works in you. And how are we going to see it? Well, we’re going to work closely with you to get that done. the thing that I didn’t mention is that the EEG usually has changes 10 to 15 days ahead of symptoms.

And this is the critical piece because I realized when that happened that there were so many times I thought something wasn’t working necessarily and it was like, well, you just didn’t give it enough time. And you could see it more physiologically, but there’s a whole, I think, cascade that happens as cellular changes kind of translate into behavior changes.

Dr. Heather Sandison, ND (53:56.015)
Yeah, there’s an art and science to this and it’s certainly a field that is still evolving. But you, I mean, you’ve trained across internal medicine, functional medicine, neurofeedback, environmental medicine, chronic infection and more. And how is it that that broad training?

Can you talk about how important you think that is to thinking about cognitive decline? Because neurology, think you go in and you’re thinking about cognitive decline, but you’ve sort of come from this, you know, like generalist into specialist. Talk through that.

Craig Tanio (54:33.238)
Yeah, so,

When I was running our chief medical officer of practice that was really dedicated to trying to keep patients out of the hospital, we kind of coined this term the expert generalist, which is, you’re kind of comfortable with how the systems are working. And then the question is, is what the lens is that you’re going to be focused on. And I think I think with brain health, it’s very clear that the research is saying you have to fix what’s

happening in the body to help the brain. And so that’s going to be a challenge for training. Historically, neurology and psychiatry kind of split off from medicine after year one, while cardiology and endocrinology split off after year three. And so we’re going to have to have a more generalist approach or a collaborative team approach to trying to figure this through.

the good news is that I think that AI and the research is going to come pretty fast and furious with ways to improve things. And what we’re going, we’re going to be drowning in information and options. know, a colleague of mine was doing a compendium of research about what data is there for interventions that could affect the brain. And I think

he had gotten to like 500 interventions or whatever that are out there. And so the question is not what can we do, but it’s a bit what should we do and what are the right things to do. And so, you know, I think that there are some people who like to focus really deeply on one thing and there are some people who like to putter around in lots of fields and I’m definitely one of those who likes to putter around a little bit more.

Craig Tanio (56:32.222)
know, kind of enjoys, you know, kind of getting out into, you know, the big picture, you know, if you will.

Dr. Heather Sandison, ND (56:40.13)
When you look ahead five years, kind of with this lens of AI, just the reality, right? I feel like I’m having to accept the inevitability of how ingrained AI is about to become in our lives if it hasn’t already. How, what do you hope will be different? Like, what will it look like? How will medicine more generally understand how to treat cognitive decline?

Craig Tanio (57:00.984)
Well, I think that…

You you could certainly look at AI with, you know, if you look at like chess, you know, what became very clear as the computers got better is that people with the computers were really the better solution for a long time. And then, you know, unfortunately, the last couple of years, even the computers have kind of, you know, gotten better that’s there. So I think any of our guesses is going to be a bit wrong after, you know, five or 10 years. But I’m

positive that from the perspective of patients.

we as clinicians are not going to be irrelevant, if you will. There is so much moral injury in medicine today, because clinicians don’t feel like they’re doing the right thing, that I think that we can use AI to help us get stuff done that we haven’t been able to before.

that our ability to do that is going to increase. We just have to be in systems that allow us as clinicians to have the freedom to be able to do that. And I’m a believer that the health care system can’t be effective without individual practitioners being independent from the health system, if you will.

Craig Tanio (58:38.992)
We need, we talk about diversity in certain things when it comes to like race and ethnicity, but I think we need diversity in terms of types of clinical practices. There shouldn’t just be one type of practice. And patients need to have that access. And the only way to do that is to really allow the individual practices to, and preserve private practice.

Dr. Heather Sandison, ND (59:05.466)
Right? Yeah, yeah. Not everyone’s a right fit. certainly that patient-doctor relationship is so important. There has to be therapeutic alliance. one of my early med school moments was this realization of I am not going to be everyone’s doctor. That is too much responsibility for me. And I’m not.

right fit for everyone, whether it’s my expertise or my approach, my personality, my communication style, the way my practice is set up. All of these things, there’s going to be preferences and we want for medicine to be accessible. We need, we need the right fit. We need to find the right fit. This is such a rich conversation and I feel like we could chat for hours and I hope we get the opportunity to continue this conversation offline and at conferences in the future. Dr. Taneo, it is such

privilege to chat with you. Thank you so much for joining me today. I appreciate both the depth of your expertise, but especially the way that you are helping to move this conversation and the science forward with the rigor and the curiosity and the compassion, right? There’s this human element that definitely shines through whenever I get a chance to chat with you.

And I think another big thing that stands out to me is that this work is not just about managing decline, but about asking better questions and looking a little deeper into how we can get patients the meaningful options and outcomes they deserve. I’m just so grateful for the work that you are doing. again, just so grateful for your time today. Thank you.

Craig Tanio (01:00:43.614)
Thank you, Heather. It’s a pleasure.