This interview was, without doubt, one of the most moving for me. What Dr. Perlmutter and his son, Austin Perlmutter MD, have created is really nothing short of a revolution in returning us to our consciousness. It directly addresses one of the biggest elephants in the room – despite what we know to be good for us, good for others, good for the planet, why do we more often than not fall short of putting that knowledge into action? We. Are. Disconnected. As a people. As a world.
Our prefrontal cortex allows us to engage in reflection, empathy and good decision making. However, when we lose the ability to engage our prefrontal cortex, we regress to a more primitive part of our brain – the amygdala – which fosters impulsivity, narcissism, and anger. It is virtually impossible to make the choices that we want to when our amygdala is in charge. And as we make those poorer choices – poor diet, less sleep, less exercise, more screen time – we reinforce our amygdala’s superior position. It’s a vicious cycle.
In short, our modern world stacks the deck against us. And what can we do?
Dr. Perlmutter gives us a unique lens through which to work with ourselves and our patients to start to support that prefrontal cortex connection. Tips to start to re-wire our neuronal circuitry in ways that will help us all make better choices. Be better people. ~ Thank you! ~DrKF
Clinicians can give patients all the information in the world, but it only makes a difference in their lives if they implement it. Why do patients so often ignore doctor’s advice? The answer isn’t laziness, defiance, or lack of willpower. It is the deep disconnect many people have from their prefrontal cortex, which compromises decision-making ability.
Dr. David Perlmutter and his son Austin wrote a new book about this disconnect and how to heal it. Dr Perlmutter is board-certified neurologist and a four-time New York Times bestselling author. He serves on the board of directors and is a fellow of the American College of Nutrition. He received his MD from University of Miami School of Medicine where he was awarded the Leonard G. Rowntree Research Award. Austin Perlmutter is board-certified in internal medicine.
In today’s episode of New Frontiers, Dr. Perlmutter talks with Dr. Fitzgerald about the new book and how patients and practitioners can heal the disconnect between the level of health they want to achieve and the decision-making required to achieve it.
In this episode of New Frontiers, you’ll learn about:
- Why patient compliance is so low
- Disconnection syndrome and how it affects all aspects of life, including personal health
- The neurochemistry of bad choices
- How screen time affects brain chemistry
- Strategies for being more intentional about screen time
- The sleep-decision making connection
- Cultivating empathy for patients and for ourselves (practitioners)
- The common factor that different popular diet protocols share (keto, vegan, Paleo, etc.)
- The vicious feedback loop involving lifestyle choices and bad decision making
Dr. Perlmutter is a Board-Certified Neurologist and four-time New York Times bestselling author. He serves on the Board of Directors and is a Fellow of the American College of Nutrition. Dr. Perlmutter received his M.D. degree from the University of Miami School of Medicine where he was awarded the Leonard G. Rowntree Research Award.
He serves as a member of the Editorial Board for the Journal of Alzheimer’s Disease and has published extensively in peer-reviewed scientific journals including Archives of Neurology, Neurosurgery, and The Journal of Applied Nutrition.
In addition, he is a frequent lecturer at symposia sponsored by institutions such as the World Bank and IMF, Columbia University, Scripps Institute, New York University, and Harvard University and serves as an Associate Professor at the University of Miami Miller School of Medicine.
His books have been published in 34 languages and include the #1 New York Times bestseller Grain Brain, The Surprising Truth About Wheat, Carbs and Sugar, with over 1 million copies in print. He is the editor of the upcoming collection The Microbiome and the Brain that will be authored by top experts in the field and will be published in 2019 by CRC Press. Dr. Perlmutter’s new book Brain Wash, co-written with Austin Perlmutter, MD, published in January 2020.
Dr. Kara Fitzgerald: Hi everybody. Welcome to New Frontiers in Functional Medicine where we are interviewing the best minds in functional medicine and today is no exception. I am so excited to be here with Dr. David Perlmutter. We’re going to be talking about his new book that he has authored with his son, Austin, who is I think a relatively newly minted MD. I’m so excited for you guys, so excited for Austin. The new book is titled Brainwash. Let me give you a little bit of the background on Dr. Perlmutter. I know he’s been on New Frontiers before and you’re certainly familiar with his work, but nonetheless, let’s go through this formality. He’s a board-certified neurologist and a four-time New York Times bestselling author. He serves on the board of directors and is a fellow of the American College of Nutrition. He received his MD from University of Miami School of Medicine where he was awarded the Leonard G Rowntree Research Award.
He serves as a member of the editorial board for the Journal of Alzheimer’s Disease, and has published extensively in peer reviewed scientific journals including Archives of Neurology, Neurosurgery, and Journal of Applied Nutrition. He lectures all over the globe, including, interestingly, institutions such as the World Bank and IMF. He’s really getting the word out far and wide. He’s at loads of universities and of course a lot of us know him from the Institute for Functional Medicine. His books have been published in 34 languages, including Grain Brain, which you’re familiar with, The Surprising Truth About Wheat, Carbs, and Sugar. There’s a million copies in print of that book. Pretty extraordinary. He’s also, and I have to pick your brain on this a little bit, David. I’m so excited about it…
Dr. David Perlmutter: I don’t like my brain being picked, but go ahead if you must.
Dr. Kara Fitzgerald: Oh my God. That’s funny. Okay. All right. Thanks for pointing out the inappropriateness of that saying. He’s the editor of the upcoming collection, “The Microbiome In The Brain.” That’s coming out in CRC and it’s just a collection of top experts.
Dr. David Perlmutter: Actually, it just came out.
Dr. Kara Fitzgerald: It just came out. Okay, perfect.
Dr. David Perlmutter: Yeah, we have a nice chapter by Dr. Bredesen, a nice chapter from Dr. Jeffrey Bland, from really leaders around the country relating the microbiome to the brain. We’ve already started is what it sounds like.
Dr. Kara Fitzgerald: Yeah. We have, and this is a teaser. The teaser question is I want you to eventually, I’ll wheel you back at some point unless you already go there, talk about obviously some key findings in that book that influenced this book. Before we jump into that, I want to just say, I want to hear a little bit about the backstory on this particular book. You write about it a little bit and it’s very interesting, and I also want to say that I happened to see you guys for a little while yesterday on Instagram Live. I happened to click in and I saw you sitting there and Austin was talking about the book and he just had a lot of really nice inspiring stuff to say, but you, I was focused on you because man, you were the proud Papa.
Dr. David Perlmutter: You bet. I am. I’ve been saying as far as this book goes and even before that, Austin who is now board certified in internal medicine, but well beyond that, he has always proven to be a mentor for me. I began saying that before he was even a teenager just because of who he is and I will continue to go through my life learning from him and this experience of writing a book with someone you love is really very exciting. I’ll tell you the Genesis of that event occurred exactly in the room where I’m sitting right now talking to you. We were just sitting back and kicking it around a little bit and we stumble on the idea that there’s this breakdown that seems to occur between the transmission of information to our patients and the execution of that information by the patient.
In other words, we do everything we can to learn as much information as possible. We read all the journals, we pay close attention to Kara Fitzgerald, we do all the right stuff, and then we do our best to leverage the various tools that we have to transmit that information to patients and print material verbally one-on-one, but there’s this huge disconnect then when patients get the information, know that it is important, and yet do not carry it out. We began realizing that’s pretty darn important because it certainly transcends the doctor-patient relationship. People are buying wonderful books that are ultimately useless to them because they’re not doing what the books are talking about. You and I know that many of our colleagues are writing incredibly powerful books, well-researched, based on science, and yet what good is it if you leave the book on the shelf or you read the book but you don’t do what they are talking about.
We realized that there was a good reason for that. There is this thing that we define in the book. We define something called disconnection syndrome, and we’re going to explore the various nuances of that term in a moment, but from an anatomical and functional perspective, it means disconnection from the prefrontal cortex, disconnection from the area of the brain that lets us make thoughtful decisions. Decisions that consider future consequences of today’s or this hour’s action as contrasted by decisions that are much more impulsive, that emanate from other areas of the brain, like the amygdala, for example. What we’re seeing happening is that people are becoming further and further disconnected from this gift that we have as humans. This incredible prefrontal cortex that allows us to be reflective and look at various options in terms of decision making and choose the best option as we look at how it may play out over time. As it relates to our health, as it relates to our relationships, as it relates to making financial decisions, getting along with our neighbors and even how we care for the planet.
These are actions that require a pretty good functioning of the prefrontal cortex. Beyond that, require that the prefrontal cortex is connected to the more impulsive parts of the brain, allowing the prefrontal cortex to calm those areas down when that connection, and that’ll be a balance of what we talk about today, that connection, from the prefrontal cortex down to those other areas we call this top-down control, when we threaten that connection, we lead to unbridled, unregulated behaviors emanating from more primitive parts of the brain, including the amygdala, that foster impulsivity and narcissism and foster an us versus them mentality. Fear and hatred. What was so astounding was that we began our exploration solely based upon the concern as to why people are making less thoughtful decisions and realized that this prefrontal cortex that we are abandoning is the area of the brain that allows us not only to make good decisions that think about the future, but also allows us to engage things like empathy, compassion, relationships with other people, and recognizing how important those relationships are.
That is transcendent across the panorama of the problems that we are facing today. What we learned, which is so apropos to any discussion in the realm of functional medicine, is that so many of our lifestyle choices will either nurture connection to the prefrontal cortex or will threaten to exacerbate this, what we call, disconnection syndrome. Not only disconnecting us from prefrontal cortex, but disconnecting ourselves from our future selves, disconnecting ourselves from our friends, family, and disconnecting us from the planet upon which we live. Boy, we rolled out a quite a bit from just this original discussion of why are our patients making poor decisions?
Dr. Kara Fitzgerald: I am just so blown away. Holy…Yeah, I’m blown away. It’s exquisite what you’ve just said. That’s one of the things I’ve always thought about at a much less rich level, I have not done the beautiful drill down. Oh my gosh, this is such an important work. I can see why you guys were moved as you began to uncover it. One of the things that we’ve known, it’s in our mission statement on our webpage, is that really when people embrace health, this holistic health that functional medicine can offer, those individuals who are able to transition into that, it seems like it’s a pebble into the pond. The ripple effect tends to have ecological benefit as well. It’s something that I’ve thought about in this abstract way and have observed it in my patients and have observed it in myself. I want to recycle a little bit more.
I want to take care of the yard. Use less water. There’s some basic things that I see emanate, but you’ve just connected it. You and Austin had just taken that and it’s a systems exploration. All systems, the spiritual aspect, the cognitive aspect, the physical aspect. And I can see you have these amazing quotes where say 90% of heart attacks are preventable, diabetes probably 90%. These are all lifestyle issues. That’s where functional medicine docs, that’s where we enter into the conversation. We have these lush statistics that basically point out cancer is lifestyle or mostly lifestyle, et cetera, et cetera. You have just very elegantly, in your introduction, pointed out why those statistics even exist, and why some of these things are elusive. Can you talk about what happened? How did we get here?
Dr. David Perlmutter: I can. I want to just tell you that as we’re having our discussion right in this moment, I too am really just taken by what this all means. Here, gosh, we’ve been working on this book for 18 months. Every word, should we use this word, that word? Should it be capitalized? I don’t know. Yet every moment like this is revisiting what this is all about and it never ceases to compel me that this is the big picture here. It’s a real holistic, if I can use that term, understanding of who we are, what we are, where we’re going, or where we could be going. I’m not even sure I remember what your last question was, but I’m going to say that how it relates to many of our touch points in functional medicine is, in functional medicine we are looking at, I think, the inclusive mechanisms that tend to explain many of our maladies. Most of what we look at tend to be environmental issues, choices that we make, lifestyle choices, et cetera. More recently in the past maybe five to seven years, we’ve been looking at not our genetic determinants, but more our genetic predispositions and the dance that occurs between nature and nurture, between our lifestyle choices, and then gene expression and the various nuances of those interactions based upon an individual’s unique gene panorama.
That said, I think getting back to the big picture, we’ve always centered for quite some time on mechanistically on how inflammation seems to be a cornerstone mechanism of so many of the issues that we are dealing with. Certainly the chronic degenerative conditions that represent the number one cause of death on our planet. when we recognize that the big players in terms of morbidity and mortality are inflammatory, as you mentioned, coronary artery disease, cancer, diabetes, and certainly Alzheimer’s disease as well, what an eye opener. That at a level above all of this, making those decisions that then enhance or detract from the risk of these conditions, making those decisions is influenced by inflammation as well. Where we’re going right now in this moment is that our decision making is threatened by making bad decisions, i.e., choose to eat poorly, choose to not get enough restorative sleep, choose to be more sedentary, or choose to distance yourself from nature. You will increase inflammation, which then worsens the decision making leading towards food choices, less sleep, more weight gain, and creates multiple feed forward pathways. When you begin to get your arms around that and you begin to understand…
Dr. Kara Fitzgerald: Let me point before you go there, if you can just hold onto that thought because I want to actually bring in another element that you put out there in your intro, and that is, so not only the poor decisions around what you’re putting in your mouth in generating the inflammation and being sedentary, et cetera, but also you disconnecting, perhaps, I’m going to ask you this, from your neighbor, being mean to your kids, or being mean to yourself and however that looks, but I don’t know, perhaps spending endless amounts of time with electronic media in front of your face and tuning out that way. Are these all connected?
Dr. David Perlmutter: Well, they absolutely are, and in the book we deconstruct each of those entry points. Most importantly at the beginning of the book to call them out. To raise awareness of everything you’ve mentioned of technology. As Christian Lange said, Nobel Prize winner, technology is a useful servant, but a dangerous master. That was in 1921. We’re not being luddites here. We’re not saying, let’s bail on the tech. We need our tech. We wrote this book based upon our research that really virtually opened us up to an unlimited amount of knowledge base to come up with what’s very timely. It’s about mindful use of technology. If we’re there just for a moment, when we recognize that 42% of the time that Americans are awake, their eyes are fixed on one screen or another, whether their phone, their pad, their computer, or television. Over a lifetime, that’s 22 years of screen time.
We can talk specifically about the direct detriment that may have to brain wiring. Beyond that, I think perhaps more importantly what we call out is that when you’re doing one thing, you’re not doing something else. You’re not exercising, you’re not preparing your food, you’re not interrelating with other people in a more personal way. Doing those things that we know help re-establish connection to this prefrontal cortex. That’s one entry point. We recognize how difficult it is when we’re online and we call out the fact that our attention is actively being sold to the highest bidder. Things pop up, that there’s clickbait and ads that are targeted for based on our previous online experience. The next YouTube video just happened to be something you might be interested in.
How does that happen? We know how it happens. Our screen time is valuable not to us as much as to others. There is great benefit to what we can accomplish using digital media, that’s for sure, but we recognize that it doesn’t take much for us to be dragged away. It’s much like meditation. When you’re involved in meditation, thoughts come into your mind and oftentimes you have to think about this, what you’re going to do tomorrow, what you did yesterday, but then you gently and lovingly are able to guide yourself back to the meditation. The same thing happens when you’re online, but it’s much more aggressive because it’s specifically designed virtually to hijack your attention. We know that it happens. It’s been said that if you have five minutes to spend on Instagram, that’s a good way to spend an hour.
It happens and we’re aware of it. As it relates to our digital experiences, we developed an acronym called the test of time, T. I. M. E., T. How much time do you dedicate to whatever it is you plan to do online or watching television? That’s the time. I., is it intentional, what’s your goal? What are you going to do? What do you want to get out of that experience? M., while you are experiencing this online time or whatever it may be. Are you M., mindful? Are you staying with it? Are you understanding and recognizing the attempts to hijack your consciousness as it were? Finally, E., is this experience ultimately enriching. Are you net positive once it’s said and done? We know that 6% of people who have access to the internet are now characterized as having internet addiction. It is a risk factor for suicide.
It is a risk factor for other medical problems, comorbidity-type issues. That’s a big number. That is a quarter billion people. It’s five times the population of Great Britain. It is aggressive what goes on online. I think that it’s really important that this experience is designed to rewire our brains, to keep us further away from our goals, and to enhance our connection to impulsivity so that we will make impulsive decisions as it relates to our online experience by those things that are being put in front of us, et cetera. I think job one for us in Brainwash was simply to call it out. I think being aware of it on the front-end is hugely important so people can see that it’s happening. In China now they have bootcamps for internet addicted people, and South Korea is now offering digital detox that people can actually reestablish connection to real humans. The average global, a person who has access to the internet, has eight and a half social media accounts. That’s pretty incredible if you ask me.
Dr. Kara Fitzgerald: You would say that this engagement in digital media, if not done very intentionally with a conscious effort at awareness, is destroying the prefrontal amygdala regulation?
Dr. David Perlmutter: Exactly. With all due respect, it’s more than the fact that I’ve said that. You’ve read the book, that’s what the science is telling us. That’s spooky because that coupled with diet, for example…
Dr. Kara Fitzgerald: Coming back to the inflammation piece.
Dr. David Perlmutter: Is threatening this connection to the prefrontal cortex. Basically taking the adult out of the room and leaving the amygdala in charge. It’s the parents leaving the kids at home, spending the weekend on a cruise where the kids are home with 30 of their closest friends, and how’s that going to end up? It takes away this top down control that allows us to make more thoughtful decisions. You mentioned anger a moment ago. Anger is this manifestation of unchecked amygdala activity.
I very candidly in the book, describe an experience that I had several years ago in a big box store when somebody verbally assaulted my wife and my amygdala took over and gratefully before anything irreversible happened, I reigned it in. I believe that things like meditation for example, enhances your ability to do so. Nonetheless, we’ve all been there. Cars are going to cut you off in traffic. People are going to forget to pay bills. Things happen in our world. It’s really how we respond to those day-to-day stresses, I think, that really defines where we are on this spectrum in terms of this connection between prefrontal cortex. Then this top-down control that we so desperately need. There’s a lot of anger around. There’s a lot of us versus them these days. There’s a lot of entrenchment into ideology that isn’t going to serve us well, and that is fostered by social media sites that cater to one way of thinking.
When we reengage the prefrontal cortex, it allows us to engage in what’s called cognitive empathy, to look at and experience another person’s point of view, and that’s how we make progress. That’s how we move the ball down the field by sharing ideas and coming up with new solutions. It’s diversity of mentality and diversity breeds resilience. We know that from looking at our gut bacteria. The more diverse the gut bacteria, the more our gut bacteria embrace each other’s ideas, if you will. I know it’s a stretch, but the more resilience we have in terms of our health. Same thing with our relationships with other people. Hey, it’s the same thing in the Amazon. The more diversity of flora and fauna, the more resilient the Amazon is to responding to environmental challenges. We need diversity.
Dr. Kara Fitzgerald: Listen, I wanted to ask you, that’s making me think of so many things. There was an interesting soil study though. I was just reading a little blurb on from scientists talking about diversity in the soil, the next generation hygiene hypothesis. There was a paper that was just published that I can…
Dr. David Perlmutter: It actually just came out yesterday. You’re right.
Dr. Kara Fitzgerald: Yeah. Yes, you’re familiar with it. Yeah. Yeah. Talking about the whole nature thing there’s a whole body of research in that arena coming out. That’s so interesting. You guys came up with this time acronym and I’m curious as you brought this into your prefrontal cortex, as you brought these ideas into consciousness, undoubtedly you were looking at your own habits and what did you find? Did you find that you were, I know that I’m falling victim to the digital trap and that some real intentional action has to happen for me. What I’m curious about is what you guys noticed as well.
Dr. David Perlmutter: Well, let me say that you bet, is the answer. That’s for sure. Both Austin and I identified so many areas that need work in ourselves in how we relate to others and in how much time we are spending doing things that may detract. That’s for sure. This is always a job in progress and we can each do better. There’s a great book I just finished reading by a fellow by the name of Dan Harris called 10% Happier. I mention that because hey, he’s only going for 10%. It’s a book based upon, he’s an ABC news reporter, it’s based upon his thought that he was able to achieve just 10% more happiness by engaging in daily meditation. It’s certainly something we work on. I could have spent a lot more time in the evenings on the computer working as I’ve done for years.
Writing books and preparing lectures, you name it, but recognizing, for example, how that might compromise my sleep. The importance of sleep as we talked about in Brainwash. It’s for reconnection to the prefrontal cortex. How lack of sleep not only threatens that connection, but also increases inflammation associated with increased levels of tumor necrosis factor-alpha and interleukin 6 in C-reactive protein. We know that inflammation again threatens not only our connection to the prefrontal cortex, but also the availability of serotonin through what I’m sure you’ve talked about the kynurenic acid pathway. These things all connect and from my personal perspective, early on I got an Oura ring and I learned that some good things about my sleep. I sleep enough. I get to sleep within seconds, but that my level of deep sleep was not where I wanted it. Deep sleep is when we activate our glymphatic system to purge the brain of its accumulated toxins, et cetera.
Therefore, I began looking at some of my choices. How late in the day I was consuming caffeine, how late in the day I was working on the computer and if I were required to get something out by the next day that I would turn on night mode, for example, and blocking blue light on the computer helped me help my melatonin levels. I was able quite dramatically to improve the time I spend in deep sleep. Have I noticed anything from that? I haven’t really, but I am a believer that if the glymphatic system is what it’s cranked up to be I want that thing working full blast for me. That’s for sure.
Dr. Kara Fitzgerald: Yeah, absolutely. Okay, so blue light on the computer, less caffeine or modulating how late you go into the day, anything else? Are those the two big things? I’m just kind of curious.
Dr. David Perlmutter: As for myself, much more dedication to regular meditation. We talk quite a bit about meditation and it’s (cerebral) aspects in the book. I think people pretty well, at least listening to this podcast today, know what that’s all about. In the context of disconnection syndrome, there probably isn’t anything as studied or as powerful as the value of meditation for helping us reconnect.
Dr. Kara Fitzgerald: Specifically referring to sleep, if there were any other little pearls you yourself found were helpful, but I do without question, want to talk about the overall approach that you’re doing in disconnection.
Dr. David Perlmutter: So at least for me, sleep hasn’t been a huge challenge for me. As mentioned, I did want to augment time spent in deep sleep, but it doesn’t mean that just because I haven’t had issues with it, there are plenty of other things in my life I’ve had issues with. It doesn’t mean that we don’t talk about a lot of stuff. We mentioned blue light. We mentioned getting a lot of natural light during the day. Limiting caffeine, we said after 2:00 PM really. Reducing the idea of eating later. Looking at the value of time-restricted eating. Making your sleeping area a sleep sanctuary. I’m all in for recommending as we talk about in the book, getting a formal sleep study as an adult. I think that’s really valuable to have a polysomnogram. We can learn a lot with wearable technology. There’s no question, but to get a sense as to a O2 saturation, the possibility of any breathing issue or a periodic leg movements, anything that’s going to disrupt the depth and quality of your sleep.
I think it’s really important to know because by and large there are a lot of interventions that you can engage that can help you get through that. A lot of people are asleep and don’t recognize their sleep apnea or don’t recognize how deeply they’re snoring and therefore threatening their oxygen saturation. This type of non-restorative sleep, though it may be seven hours in length, is associated with a significant increased risk, for example, for type two diabetes, cancer, and even Alzheimer’s, likely through the augmentation of inflammatory pathways. The problem though, as it relates to disconnection syndrome, is that, and we’re all familiar with this, even one night of non-restorative sleep is associated with dramatic increase in impulsivity. In one study that looked at how people respond to looking at a picture that might be threatening while they’re in a functional MRI machine. People who had a good night’s sleep versus people who had a non-restorative night, didn’t get to sleep basically.
They ran an MRI machine next morning. They show them a picture of a challenging face, a threatening face. Those individuals who didn’t get a good night’s sleep have a 60% increased activity in the amygdala in comparison to those people who had a good night’s rest. The other interesting thing is there’s a study called delayed discounting. It basically is a measurement of impulsivity. Impulsivity is dramatically increased in lockstep with not getting a good night’s sleep, and what does that translate into? It translates into making not thought through decisions, decisions that are impulsive, that relate to things like choosing food that’s not necessarily good for us. We know that when we’ve been up all night that our likelihood of eating foods that are not necessarily good for us and we know that is much, much higher, and that for people who chronically are sleep deprived, their average daily increased caloric consumption is about 380 kilocalories. That’s without an increase in energy burn. It’s a net 380 calories more, and when it only takes 3,500 calories to equal a pound of body fat, you could see how this very quickly translates into weight gain, which does what? Further compromises your ability to get a good night’s sleep, more bad decisions, more poor food choices, and yet another vicious cycle.
Dr. Kara Fitzgerald: Right. More of the inflammation that underscores all of it. It’s really extraordinary the multi-level involvement of disconnection syndrome. David, you’re just making me think of being interested in epigenetics and having finished our study and writing it up, it doesn’t take much sleep deprivation at all to show genome line changes in methylation and actually acceleration of the epigenetic clock. Accelerated aging with not a heck of a lot of sleep deprivation. To me, I think about those epigenetic changes as perhaps being more resilient. It’s not one Snickers bar where you see your sugar go up for X amount of hours and drops down. Although that can change epigenetic expression also, but you start to kick in something lasting that is arguably contributing to some of those behaviors. You just outlined that happened as a result of poor sleep.
Dr. David Perlmutter: Well, it’s true and it is all about, I think, recognizing how powerful our lifestyle choices in terms of our gene expression and beyond that. How there are uniquenesses that are based upon our single nucleotide polymorphisms that may make situations even worse for some people. I really believe that we’re going to be learning much more about that. For example, sleep, there’s plenty of information that looks at how food influences gene expression and how uniqueness is expressed into ultimately phenotypic expression based upon these interactions. We’ve certainly come a long way from genetic determinism to this idea that we powerfully influence. It was, when I used to talk about this, we used to say 70% of the genes that are involved in longevity and health are under our control.
That number is now close to 90% and that is compelling on the one hand, but to spin it, I’d say it’s certainly empowering because that allows you then once you understand your genome and you’ve been able to go through it with somebody who can provide those interpretations, looking at your methylation pathways for example, looking at inflammatory pathways, what your risks are and how you can offset that. This relationship between inflammation and poor decision making, impulsivity, and fostering an us versus them mentality, I think is something to think about as it relates to inflammation caused by diet, specifically the Western diet, which is becoming the global diet. What we’ve just connected then are changes happening to nutrition on the planet that are locking us into impulsivity, self-centeredness, and us versus them mentality based upon the changes that are happening to what people are eating around the globe. Basically, the food changes that are happening, nutrition changes globally, are changing the mindset. Changing how people see each other around the planet.
Dr. Kara Fitzgerald: Yeah, it’s the multi-track action of poor diet, lack of sleep, screen time, screen time that’s dictated by corporations as you point out, clickbait, and so on and so forth. And all of these things really profoundly alienating us. Can you talk about the solution? How do we unpack this with our patients? How do we approach it? Again, just thinking about my own practice, I’m a functional medicine doctor, so lifestyle interventions are a part of what I do with all of my patients, but as I was reflecting on our conversation, I was visualizing the treatment plan and they actually fall at the bottom of my treatment plan, which means sometimes they’re not going to be front and center. I’m listening to you and I can see that the lifestyle interventions that fall at the bottom of our matrix sheet too, they really need to be up at the top. The things that we’re putting so much energy and time into. How do we approach our patients really armed with this extraordinary knowledge that you guys have written up and unpacked for us.
Dr. David Perlmutter: The frustration that we feel is, I think, we have to ask ourselves, do we blame patients? I would say yes. I’d be the first to admit my guilt in that. Wondering, I’ve given you so much information and yet your blood sugar is higher than it was last time. You’ve gained eight pounds. You’re obviously not doing what I instructed you. There’s so much involved in that right off the bat. It’s paternalistic, it’s aggressive, and it’s blaming. I think we have to first embrace the idea that the deck is stacked against our patients. The deck is stacked against ourselves. The modern world is stacking the deck against each and every one of us. The doctor-patient relationship, it’s really quite evident because your patients know what the good actions are. They get what you are telling them.
They know darn well that they need to walk for 30 minutes a day. Whatever it is you’ve told them to do, eat more vegetables, stop smoking, whatever it may be, they cannot make that decision. I think it’s so important that we stopped blaming them and so important for each and every one of us to stop blaming ourselves for not doing X, Y, or Z. We all have goals. We all know that there are things we should be doing and get down on ourselves for just not being able to carry it out. Whether it’s, me saying, oh, I want to be time restricted tomorrow and not eat until four, whatever it may be, or a patient saying, I’m going to get up and walk around the block one time tomorrow and then not do it and blame himself or blame herself, and then healthcare providers blame them as well.
We’ve got to come to the understanding that the deck is stacked against us. It’s not meant to sound like a conspiracy theory, but we understand that sugar now added to 68% of the 1.2 million foods sold in America’s grocery stores, hacks into our valuable survival adaptation, in other words, our sweet tooth. We all have a sweet tooth because in our more hunter-gatherer days, it told us several things, that the food was safe, that the food was ripe, and it also gave us sugar to increase insulin, to lay down some fat so we could survive through the winter. Very adaptive type of a desire that we have for sweet. These days it’s hacked into. It’s hacked into specifically manipulating our food sources so that we will continue to eat these foods. Our desire for interacting socially is also a powerful survival adaptation, allows us to live in groups to protect each other, to have specialization of tasks based on ability, et cetera.
That adaptation is being hacked into by this thing called social media which by and large is not. That’s how it works. Earlier in our conversation we talked about how prey we are to this online manipulation for example, but it happens on television it happens in all corners of our lives that we are first made not to feel adequate enough, not good looking enough, thin enough, rich enough, tall enough, whatever it may be inadequate. Here is the quick fix. Do this by this and everything will be good. Well that’s a short-term, instant gratification that does nothing more than through neuro-plasticity strengthens our wiring to the amygdala, while at the same time causes further withering of our connection to the more appropriate decision maker, the prefrontal cortex. The more we do it, the more challenging and difficult it becomes to get out of it.
Let me get back to then, what do you take to your office? I think first of all is this understanding. Tomorrow morning when you are seeing this patient who is just not doing what you think she should be, and beyond that, is not doing what she thinks she should be and knows damn well she should be doing and wants to do, but can’t bring herself or himself to do. It’s this understanding, again, that so much of our modern world is conspiring to keep us from being able to make these better decisions. What do we do? We want to get back on the carousel and we don’t have to jump on the carousel at every entrance point, every on-ramp. If we can do one thing, it’ll help our decision making moving forward. Now what might that one thing be? Really depends on the patient.
If this happens to be someone who’s significantly overweight, it might be simply paying attention to that individual’s sleep hygiene because quality of sleep affects dietary choices, affects impulsivity that relate to food choices the next day. That might be the entrance ramp for that individual. It might be simply engaging in a meditation program. It might be looking at that person who spends all of his or her time indoors to say, hey, look, 80% of our time is spent indoors and another 60% is spent in a car, and guess what? It turns out that nature exposure reduces inflammation, reduces cortisol, both of which, inflammation and cortisol, threaten our connection to the prefrontal cortex, threaten our ability to make better choices. Why don’t we see if we can get you outside for 10 minutes a day or 20 minutes every other day?
If that’s a no-go for whatever reason, patient lives in a place where that just can’t be. Step two, okay, can’t do that. Why don’t we try bringing in a couple of houseplants into your kitchen, into your dining room, or even bring a plant to work. It’s bring a plant to work day for you and leave it on your desk. Now, if that won’t work because they don’t allow plants at work or you don’t want to be caring for a plant, even a photograph of a natural environment lowers inflammation, lowers stress, lowers cortisol, and allows a slight uptick in the dedication and the ability to make better decisions. Once you get your foot in the door, we’re all in. Give us a little crack in the door and we’re going to ultimately pave the way for, not a feedback cycle that worsens with time, but a feed forward cycle that ultimately manifests in making better decisions. Better food choices foster better food choices. Better food choices foster better sleep. Better food choices foster more dedication to exercise, for example. Isaac Newton told us that an object in motion tends to remain in motion and that means that when we choose to exercise and get an emotion that fosters better decision making. Tomorrow we’ll remain in motion. We’ll do more exercise.
Dr. Kara Fitzgerald: Thank you so much for that. A lot of behavioral shifts starting very gently. Really meeting the person who’s allowing us to walk with them on their health journey. Really meeting them where they’re at and dialoguing about what they’re interested in doing. Yeah.
Dr. David Perlmutter: You know who really benefits from that? You do. Dalai Lama said that if you want others to be happy, practice compassion. If you want to be happy, practice compassion. Though, hey, maybe that’s selfish and I’m all in, what the hell? That’s what motivates us. You’re going to benefit by engaging this empathy of now seeing things through that individual’s eyes that he or she can’t make those decisions, that he or she believes things in a certain way. You’re going to be with that. Gosh, maybe not you, but I have thought to myself over the years that when you see individuals who are significantly overweight, why don’t they just make better decisions? Well now I know why, because, A. they’re overweightedness is causing them to make worse decisions and overeat, for example. Gary Taubes says that we’re not overweight because we eat too much.
We eat too much because we’re overweight. We need to embrace the idea that our fat cells have an agenda. We talk about cancer cells for example, doing what they can, manipulating our immune systems, making them less efficient, less appropriate, and enhancing angiogenesis to improve their blood supply, and doing all these things to fight for their survival. Unfortunately, our fat cells do the same thing. More activity we have of our fat cells, the more we lay down fat, the higher is our body inflammation, the higher our ghrelin levels that increase our appetite. In a very real sense, our fat cells are paving the way for us to gain weight while at the same time compromising our sleep, which further compromises our decision making.
Dr. Kara Fitzgerald: Yes. Yeah. I want to just, as I mentioned in the beginning talking about the microbiome, I think, really everything that you’ve just said can be influenced by what’s going on in our microbiome. Of course we’re going to be biasing our microbiome based on what we’re eating. Again, it’s this vicious cycle.
Dr. David Perlmutter: It is important to call it out as a vicious cycle. That’s part one. It’s happening. I get it. Now that I get it, what in the heck can I do? That’s the positive part of the messaging here. That’s why we wrote the book, because it’s very clear that these things can be reversed. Does it take some work? You bet it does. This is the way, even, in the doctor-patient relationship, which is, this book isn’t geared specifically for that, but you can clearly see how much play it’s going to have in that area. Even in terms of that, by engaging this understanding, this becomes top level. I mentioned earlier, there’s some wonderful books out there written by people that you and I know. Great books. We see them coming out left, right, and center. We see the public television programs, great information. Guess what? These books, these programs are totally useless. A complete waste of time if people are not able to implement. We created Brainwash to be the bridge then between information and action.
Dr. Kara Fitzgerald: It’s extraordinary.
Dr. David Perlmutter: You embrace what’s going on around us. The fact that our attention is sold to the highest bidder. Our brain and our decision making is being hacked and our brains are being rewired, locking us into impulsive behavior and distancing us from being able to relate to our prefrontal cortex. It’s time, A, to call it out, and B, to reverse that situation. Incredibly, so much of what we have identified are similar recommendations that we’ve been making for some time as it relates to stress, cortisol, and the other touchpoints of the functional medicine matrix.
Dr. Kara Fitzgerald: The conversation is really around freeing people of the burden of blame in this educational piece, which is just extraordinary. It reminds me of when the tobacco industry was really outed for their nefarious brainwashing ways. It falls in there, or sugar, big sugar, and some of the other…Yeah.
Dr. David Perlmutter: When you recognize that in the old days to determine how to advertise your product, you would do what’s called a focus group. You get a bunch of people in a room and you’d run various ad touchpoints to a group of people and they would respond in one way or another. Now advertising involves the use of functional MRI scan to determine what specific messaging is lighting up the reward center. It’s really hacking into an individual’s brain and that’s what we’re going to go with. That’s what we’re up against. That is the very leading edge of technology of neuroscience being used to manipulate us to make choices that are not necessarily good for us. As I mentioned earlier, this addition of sweetener to our foods, what a powerful hack that is. It’s so, I think, valuable and empowering to have that called out. We begin to recognize what in the heck is going on around us, and decide with baby steps becoming adults steps that you don’t want to participate in this anymore.
Dr. Kara Fitzgerald: We don’t want to be unwitting puppets of some corporate interests. Yeah. We might start that by bringing a plant in the office. That might be the first little toe in the door of an inner revolution.
Dr. David Perlmutter: It’s so important. It’s not just important for the readers of this book for themselves, but again, I want to get back to the existential value of our reconnection not only to each other, but what is demonstrated is that there’s this relationship between activation of the prefrontal cortex and pro environmental behavior. This is all getting back to your relationship with ourselves, our future selves, our neighbors and families, our communities, and the viability of the planet on which we live. My goodness. It’s a very big story and our hope is that it’s a beautiful story It ends in a very powerful way with tools for empowerment, tools for change that allow people to, as mentioned, A. recognize that this is happening, and B. offset those things in very meaningful ways that are not in and of themselves individually very challenging, and that feed forward, pave the way and enhance the likelihood that more of them can be added.
Now is it dietary specific with the exception of having the goal in terms of dietary recommendations to be anti-inflammatory? So many of the very good diets that we are seeing these days ultimately manifest in reduced inflammation, whether it’s a Mediterranean diet or modifications in the Mediterranean diet, more of a ketogenic diet, a vegan diet, or at least more vegetarian. These things all tend towards lower inflammation with the real goal being to dramatically reduce the consumption of sugar and other forms of highly refined carbohydrates as well as ultra-processed foods, to call them foods I think is a misnomer, which we know have direct effects in terms of augmenting inflammation. In other ways, enhancing our loss of important cofactors, minerals, if you will.
These are things I think that unite the wide array of really terrific ideas in a nutritional recommendations that we are seeing from our colleagues, which by and large are not good advice, but great. You want to do that type of diet, hey, have at it. This is what you really resonate with from what you’ve read. Fantastic. What our goal is to give you the tools to make that happen. You want to go all in on Paleo? Great. Here are some ideas to think about Paleo. You really don’t want to go hog wild, no pun intended, on the meat, and if you do grass-fed, wild fish. Fine. You want to be vegan? Wonderful, terrific diet, good for you, good for the planet, but be cognizant of your need for vitamin D, vitamin B12. A couple of other ideas that you may want to consider. What is your source of iron, et cetera? Here you go. That’s what you want to do for whatever reason have at it, but here are the tools to give you more of the ability to commit and to follow through on your choice to be vegan, Paleo, or ketogenic, whatever it may be.
Dr. Kara Fitzgerald: I got it. I’m excited to see, you’re launching this into the global consumer space for everyone. It’s launched for everybody, but I can see your ideas really infiltrating how we’re thinking as clinicians, and inform our teaching in IFM and beyond ideally because you’re connecting some extraordinarily important points.
Dr. David Perlmutter: The goal here today is really connecting to the clinician first. Heal thyself first and then recognize the power of that empathy part by then transmitting to the patient that information. Interestingly, we’ve learned that this emphasis on decision making transcends the health arena. We were just contacted yesterday by Great Britain because they have looked at our book in an area that we didn’t really consider and that is, how people make decisions with reference to their finances. We’re all about health and they said, yes, your book is so valuable because so many people are making impulsive decisions with respect to their investments and this, that, and the other and they’re not looking at making more well thought out decisions as it relates to how they handle money. Wow. There you go. We don’t want to be impulsive in our money handling. That’s for sure.
We want to be able to think about the future, how it may play out, and I’ll tell you, I’ve never had this experience with Brain Maker or Grain Brain that prior to publication here in America that the book was acquired as it relates to the Brainwash by 16 other countries. I am really, really excited about that. Russia, South Korea, Turkey, Lithuania, Italy, France, Germany, Portugal are going to read this information in their language and I’m very hopeful. I’m very hopeful that whatever segment of the population can, first of all, realize what’s going on with respect to our call it what it is, mental manipulation A and B, gain some tools to do their very best to offset this and ultimately to reengage in empathy and to tamp down the us versus them mentality and to recognize that, Kara, we are in this together. That’s what holistic is all about.
Dr. Kara Fitzgerald: Right, right, right. What a beautiful way to wrap this podcast up and I’m just so excited to get to be a part of the launch. I’m just so thrilled to be able to be here talking to you about it. I feel a lot of gratitude, which I think is one of the ways we can loosen that knot. Yeah, David, thank you so much for this work and what a blessing that you’ve got to do it with Austin. I wish you the best and we’ll support you and root for you and put the word out.
Dr. David Perlmutter: Oh, you’re making me feel so, so good right now. I have so much gratitude in my heart for you, for the work that you do, for allowing me to share this time with you today. Thank you.
Dr. Kara Fitzgerald: Absolutely an honor. All right. Take care.
Dr. David Perlmutter: Bye. Bye.
Dr. Kara Fitzgerald: And that wraps up another amazing conversation with a great mind in functional medicine. I am so glad that you could join me. None of this would be possible, through the years, without our generous, wonderful sponsors, including Integrative Therapeutics, Metagenics, and Biotics. These are companies that I trust, and I use with my patients, every single day. Visit them at IntegativePro.com, BioticsResearch.com, and Metagenics.com. Please tell them that I sent you and thank them for making New Frontiers in Functional Medicine possible.
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