Season 6, Episode 2: Maximizing Brain Health and Longevity with Dr. Austin Perlmutter

Evelyne: We did. I’m so happy you’re here today. So a little background, Dr. Austin and I met recently at the Mexican Association of Lifestyle Medicine Conference in Mexico City in October. We were both speakers and we rode the shuttle every morning with everyone from the hotel to the conference, which was so fun. It was during Dia de Muertos and it was just such an incredible time and you gave a fantastic, fantastic talk at that conference, which is why I wanted to interview you. So thank you.

Dr. Austin Perlmutter: Well, thanks for having me.

Evelyne: First of all, to start off, what is lighting you up this week?

Dr. Austin Perlmutter: Well, it’s a great question. How much time do you have? I know that you know this, but I work with Jeffrey Bland, who is a PhD, started the Institute for Functional Medicine and Jeff, he reads more journals than I even knew existed. So every week Jeff brings in a stack of journal articles and we just start talking about this, that, or the other, so there’s always new content. But I think in terms of what’s most interesting right now, so I’ve been in conversations with Jeff and my dad, David Perlmutter, and then some other physicians about what are the major drivers of disease in the United States and what are the pathways that are involved that we can actually act upon, and what are the practical interventions that make sense to intervene on those pathways?

And what seems to be happening is a convergence in understanding that the epidemics that we’re seeing right now in the United States of chronic disease and specifically chronic preventable disease, are being driven by something called immuno-metabolic dysfunction, which is this intersection of unhealthy immunity and unhealthy metabolism that manifests as cardiovascular disease and risk for Alzheimer’s, then depression and diabetes and obesity and premature death. And it really feels like right now we’re getting to the place where the science is demonstrating that this is the key pathway, both in terms of understanding where things go wrong and in terms of understanding where things can go more right.

And so we’re starting to see interventions that can act on this and provide substantial and rapid improvements in health and the elevation in this conversation, the translation from the research into the public consciousness is happening in real time, so that’s really exciting. It feels like never before have we seen so many people care so much about preventive health. Certainly it’s gotten wrapped up in politics and a number of other variables, but the bottom line is people are caring more and there’s science to show us what we can do about that compassion and caring for human health and caring for making better health available for people. So that’s making me passionate right now as we get into, this is a Friday, so we’ll see what today brings.

Evelyne: I love that. And I completely agree with you. We really have seen a shift recently, and I think part of it is social media. People are just more aware, asking more questions, and it’s exciting to see all the things that so many of us have cared about for, I don’t know, like 20 years that finally it’s part of our conversation with the general public. So you brought up your dad, Dr. David Perlmutter. I’m curious. He’s obviously a well-known figure in the world of functional medicine and neurology, and I imagine that growing up with him as your dad must’ve been fascinating. So I am curious how that shaped your perspective on health and medicine and did that inspire your career path or did you find your way there independently?

Dr. Austin Perlmutter: Yeah. It’s a little of everything. So part of this is the specifics of my dad and who he is in the medical world. And part of this is the more general piece of what it is to grow up and have a desire to differentiate yourself and find your own path in life. So yes, my dad is a doctor. Also his dad was a neurosurgeon, so it wasn’t like it was a brand new thing. There’s definitely this vertical transfer of kind of medical expertise that had happened in the family. I think growing up I definitely appreciated the significance of what he was doing for people around their brain health. And when I saw people come up to him, talk to him about how helpful he had been, that was meaningful. Seeing him in a hospital-based setting, you know, he used to bring us to the hospital when he was on call when we were kids. It helped me to understand a little bit about where things were going wrong and what brain health issues looked like, specifically brain health diseases. He really focused as a neurologist on both stroke and Alzheimer’s and Parkinson’s.

But with all that said, my goal was to do something else. And so I majored in English in college. My plan was to become a young adult creative fiction writer. And I kind of had this thought, which was, you know, I’m passionate about this thing, which is creative writing and writing in general, but I guess I’ll do pre-med as a, because maybe I thought in the back of my mind I probably need to at least carry that for a little bit longer. And for a number of reasons, what happened was I decided not to go into writing. You know, it’s funny, I sat down with some of my mentors and they said, you know, it’s a really tough time right now to be a writer, not a lot of positions. It’s a really tough market. And so they were recommending that I went into medicine. And at the time I was saying, you know, okay, fine. I guess I did like the science, of course. So I just decided to go, I guess, through the steps of the different courses to go into being able to apply for med school.

So I’ll just compress a lot of years into a very short amount of time. I did med school. I did residency. And the main interest I had in this was the understanding that there were diseases and medical states around the world, and especially in the United States, that were preventable and that we could significantly improve using lifestyle medicine. And what I found in the course of those seven years of training was that despite that knowledge being available, that it didn’t really matter in practice because everything in conventional medicine is based around, yes, there’s some preventive care, but for the most part it’s based around treating disease. And so what I found is that a lot of the skills that I learned in my writing training, and especially in just thinking about what it was to write, became a lot more relevant as I went through my medical training.

So I started blogging for a website called MindBodyGreen as a medical student, and then I kind of carried forward with starting to do some education and working with a group at the University of Miami initially and then doing some more education afterwards in residency to find ways to take data, information specifically about lifestyle medicine and make it accessible to larger groups of people. And so what wound up happening is that I had this initial desire to differentiate myself by being a writer, specifically a creative fiction writer. That passion for writing has actually become a far more significant part of my life now, but it’s through the lens of educating people on why lifestyle medicine matters and in particular getting to what is going to be most applicable, both in terms of building curiosity and the tools and tips that can allow people to hopefully expand their skill set so they can apply that. And that applies to both practitioners, obviously many people listening to this, watching this are practitioners and to the general public.

So I guess kind of a bit of a roundabout story here, but I was made aware of the significance of what it meant to be a doctor early on and how you could positively impact people’s health as a doctor. I became a bit disenchanted with the idea that I was going to work one-to-one with patients and kind of fight against a system in which care started at the time of disease. And then I found a way to mesh my desire to educate and to write and to tell stories that could improve people’s lives with my medical skill set, which I guess in some ways is where we are now.

Evelyne: That’s awesome. Thank you so much for sharing. And I guess it is never too late to write that nonfiction work or that fiction work if you wanted to. Right?

Dr. Austin Perlmutter: I’m working on it.

Evelyne: Oh. That’s amazing. I love that. And you get to use your English every day and you’re speaking and writing. I love that.

Dr. Austin Perlmutter: Speaking it right now.

Evelyne: Yes. So to set the stage a bit more, something interesting that you talked about in your presentation when I was watching you in Mexico is how our decision making is affected by our brains rather than willpower. And so much of what we think in society is based on psychology is actually based on biology. And I know there’s nuance to this, but tell us more about that.

Dr. Austin Perlmutter: Right. The question that I would have people think about and reflect on for a moment is why do you think, why do you do, why do you feel the ways that you do? And I don’t know that many people spend the time to actually ask those questions and to sit with the responses because it gets to maybe some uncomfortable answers. I think that we, in general, operate in society through a belief system in which we kind of think, well, I do the things I do because I want to do them. I think the things I think because that’s just a reflection of me and I feel what I feel because things happen and then the feelings result from those things happening. And then we use psychology as a way to understand at a high level that these are reflections of the mind. And I’m not discounting the role of the psychological component to understanding human behavior, but I think historically, and especially now, we somehow have forgotten or ignored the fact that psychology is a manifestation of biology.

It’s not like psychology exists in some other domain, that the mind is not something that exists outside of the brain. I know some people maybe disagree with that, but that how we think, how we act, and how we feel is a neuro-biological outcome. And why that is so important understand is that despite the fact that we’re in the 21st century, we largely view decision-making and behavior, in terms of whether somebody does something healthy or something good or bad, through the lens of willpower when we’re adults. Right? So if a kid does something they shouldn’t have done, we maybe don’t say, okay, well they’re a bad kid, or the willpower was low. But as an adult, if you see your friends and they say they want to exercise, and they watch TV on the couch or they say they want to eat healthier, but they’re eating a bag of potato chips, we think to ourselves this is a willpower deficit, willpower kind of being this psychological construct that directly stems from a sense of a person’s strength of mind, strength of character.

So it leads us to where most of the time people go, which is if a person doesn’t make healthy choices, we blame them for not having enough willpower. And the downside to this is we never actually get curious about why people make the choices that they do, because the answer to that question is in neurobiology. And what we can see is, I mean, if you go real technical through the field called neuro-economics, that the firing rates of neurons can help us to understand how people make decisions. But if you take that one step back and ask, how do biological systems influence decision making? And these are systems that people are aware of but somehow don’t connect to our thought patterns. How does the immune system, and in particular, inflammation bias decision-making, how does metabolic state change decision-making and how do therefore lifestyle variables influence the way that we make choices? There are answers to these questions, but this is not the way people typically think about things.

And for me, in medical training not that long ago, we learned about the transtheoretical model of change, and people have probably been familiar with this, the idea that, you know, you’re in this pre-contemplative stage and then eventually you move closer and closer to making a change. So you think about a person who you want to get them to stop smoking. Well, where are they along this continuum and how do we move them along the continuum? By asking them certain questions and understanding their barriers to change. And I think these things are helpful frameworks, but what if we were to also ask why is a person’s decision-making being biased in an unhealthy way by their biology? So just to give you an example of how significant this is, many people ask me, what is the one thing you should do or I should do if I wanted to improve my brain function right away? And I would say, well, look, we know exercise improves brain function. We know that healthy diet improves brain function. We know that meditation improves brain function. But those are not things that people necessarily enjoy doing.

There’s this popular myth that if more people knew that exercise was good for them, they would exercise. And I just don’t think that’s the it works. People know these things matter, but they still do the opposite. But sleep is enjoyable and sleep dramatically enhances decision-making. By that, I mean, if you take people and sleep deprive them, the next day, they will be more impulsive in terms of decision-making. When it comes to food, they will eat hundreds of additional calories preferentially from unhealthy sources the next day. Now you could say, well, they just don’t have willpower the next day. But clearly something happened with their biology as a reflection of sleep deprivation that relates to their brain’s metabolic sensors that then leads them to consuming more food. So the point I’m making here is psychology matters, but I think it’s time we introduce additional data. And for all those people who are out there, practitioners seeing patients trying to understand why it is that their patients are non-compliant, yes, it’s important to understand a patient’s home state. Right? So are there stressors at home that make it hard for them to take their medications? Are there barriers to their getting to the gym? But I think that all of us as kind of scientific-based people should also be asking the questions about what can we do at a systems level to augment their brain’s ability to make healthier choices. Simultaneously that helps us to make their healthy choices more likely for them. And it takes away this blame that we typically place on patients and on each other when we don’t make healthy choices. And it replaces with scientific curiosity and empathy for the way that our bodies operate.

So there are a lot of kind of conceptual pieces there that I’m bringing together, but the bottom line here is that instead of blaming people for their decision-making or how they feel, we should be curious about the underlying biology, even when that’s ourselves. So if you wake up and you’re feeling mad at the world, it’s sometimes interesting to ask, well, is this a reflection of something biological that I can understand? Am I sleep deprived? Am I stressed? Have I not had enough healthy food to eat? Am I coming off of a sugar crash? Because once you can start to make those connections, it takes away a lot of the power that comes from being in those negative states. And it helps us to understand our friends, our family, and our patients when they do things that we would say, this doesn’t make sense to me.

Evelyne: Yeah. And I think this is so interesting because I think a lot of us as practitioners, we have learned this at some point regarding neuro-inflammation. But like you said, how often do we still blame ourselves even when we know that this is going on or get frustrated with a patient or client because they won’t do something? And I want to talk a little bit more about brain inflammation specifically and how it’s connected to systemic inflammation, some of the mechanisms of how that works. Is it a bi-directional relationship? Talk more about that.

Dr. Austin Perlmutter: Sure. So let’s start with the basics. What is neuro-inflammation? This is a term that many people are familiar with, have heard about before, but I think similar to systemic inflammation, it can be a bit vague unless you tether it to some specifics. And so there’s not a overt consensus in the scientific literature as to here are the diagnostic features of neuro-inflammation. And in part this is because we could still look at kind of a pathological or histological diagnosis where we say, well, you need to do a biopsy of the brain and see certain types of immune cells, which nobody’s really doing kind of in standard clinical practice. You might do this in a hospital setting if you’re trying to figure out whether a person has infection or neoplasm. But the things that are relevant to consider here is that neuro-inflammation is kind of characterized by increased levels of inflammatory cytokines. And so these are inflammatory proteins like interleukin 1, tumor necrosis factor alpha. And additionally, what you see is an increased activation of a cell called a microglial cell.

And so one of the big re-conceptualizations of the brain is that it’s not just about the neurons, that roughly 50% of the cells in the brain are these glial cells. And one of the most important of these, although they’re all important, is the microglial cell, which is kind of a macrophage that lives in the brain, and microglial cells can become activated and can enhance inflammation in the brain. So one of the hallmarks of neuro-inflammation is an activation of microglial cells towards what we call an M1 subtype, which is associated with inflammatory brain states. You may also see increased infiltration of peripheral immune cells. And so the prototypical example of this would be in multiple sclerosis, you would see these autoreactive T cells coming into the brain, and then you might also see damage to brain tissue as well as damage to the blood-brain barrier. So these are all kind of hallmarks of what we would call neuro-inflammation. Importantly, and as you’ve already alluded to, you’re not necessarily going to get this data from conventional tests that you would do in the clinic.

So most people are not doing brain biopsies in the clinic, if they’re worried about their patients having neuro-inflammation. Similarly, many people may not even do kind of advanced brain imaging that tells us about some of these things. So there are specialized brain scans that can tell us about whether microglial cells have increased activity by looking at things like translocator protein TSPO, but most people are not ordering that in the clinic. And so I think that the relevant piece here is to understand that if you were to have access to a human brain, these are the things that were happening in the brain. But to take a step back, we would ask, okay, how do we have proxies or surrogates for these brain states that we can measure in the periphery? Or maybe even more importantly that we may get an indication that brain inflammation or neuro-inflammation is a risk because of something happening that we get easy access to. And so examples of that last variable would be higher levels of hemoglobin A1C or just metabolic dysfunction. That is a surrogate for risk for neuro-inflammation.

Similarly, generally having a higher BMI, even though it’s not the perfect measurement, but more visceral fat in particular may be a surrogate for having neuro-inflammation. And then there are a number of disease states that may also tell us something about risk for neuro-inflammation, things like TBIs. These are also risk factors for neuro-inflammation. So just to kind of put this into context, it’s one thing to say, here’s what’s happening in the brain. It’s another thing to say, how do we get a sense that this is happening in the brain?

And so for most of us, I think the focus should be on understanding that neuro-inflammation may be a driver of cognitive issues, everything from Alzheimer’s to mild cognitive impairment to poor decision making and mental health issues like depression. I would say depression is probably the best substantiated in terms of correlation with neuro-inflammation, but even PTSD and even what we’re learning now is things like violent behavior. That may have correlations with neuro-inflammation. So we need to start asking these questions around these behaviors, around these mental states as to what is happening in the brain and specifically what is happening with our brain’s immune system. And then what can we do about it?

Evelyne: And thank you for sharing those markers because I know there are more specialized tests, like even if you have antibodies to, you know, like cerebellar antibodies, things like that. But I know that it’s kind of hard to test. It’s expensive to test. But then I guess we can also determine based on a patient’s symptoms that they probably do have neuro-inflammation. Right? And I’m still curious about the link between systemic and brain inflammation, the mechanism there. So if you have inflammation in the rest of your body, I know that our brain is part of our body, but is there something happening in the blood-brain barrier where it’s crossing or is some of that inflammation actually just starting in the brain and then maybe going the other way?

Dr. Austin Perlmutter: This is a really good question. So I wouldn’t say that we have a single answer to the question, and I think that’s really important. I know that some people might say, well, the whole thing is a breakdown of the blood-brain barrier, but it doesn’t seem like that’s the case. So let’s kind of talk about some of the pathways involved here. The first point to make is that the brain is not separate from the body, and you’ve already brought this up, but there is a bidirectional and persistent communication between what happens in the body and what happens in the brain. So the brain is not locked away in this box that doesn’t communicate with the body. The best way for most people to understand this seems to be with the understanding of this gut brain access. This has kind of leapfrogged out of scientific literature and into the public conversation around health where everyone’s talking about gut health and a substantial subset of people are talking about how gut health influences the brain. And I’m sure you’ve heard many of these things.

So people say, oh, well the majority of your serotonin is produced in your gut, and since serotonin is so involved in mood, this means that the gut influences mood. Now, I think that’s great as a way to get people interested, but it’s not accurate because serotonin in the gut doesn’t go through the blood-brain barrier. However, what does happen is that the serotonin in the gut can influence what’s happening within the gut, including in the gut’s immune system, and that may then influence the brain. We know that what happens in the gut has kind of a major conduit to what happens in the brain by way of the vagus nerve. And so signals from the gut, either through the gut’s immune system or through the microbiome of the gut or through enteroendocrine hormones can bind to and influence how much the vagus nerve fires, and by doing so, conveys data from food from the microbiome, from the outside world to the brain.

And we now know from a host of different studies that this has an impact on basically every aspect of brain function from formation and health of our neurons to the polarization of our immune system in our brain, the microglial cells to the health of the blood-brain barrier, because we know that, for example, short-chain fatty acids, which are produced by microbes in the gut may actually promote a healthier blood-brain barrier. So point here being gut is a good example of showing how what happens in the body influences the brain. And because it used to be we would say the majority of the immune system lives in the gut. Some recent research suggests that’s not quite accurate, but a huge component of the immune system does live in the gut, and that means that what happens in the gut plays a major role in systemic immunity, and that systemic immunity is going to influence the brain. So how does that happen?

Well, there are immune signals, as we said called cytokines, and these cytokines may bind to immune cells to amplify their response, or they may find a way through either through receptors or otherwise, the blood-brain barrier to influence the brain and the microglial cells in the brain. Immune cells in the periphery can also influence what happens in the brain. So if you have a really intense inflammatory response in the periphery, you know, something like let’s say you have sepsis, all of the cytokines and immune cell activation in the periphery is going to influence what happens in the brain. How does this happen? Well, maybe partially because of what happens with the blood-brain barrier. It may be through receptors on the blood-brain barrier that translate that signal. It may be through the vagus nerve. There are also parts of the brain that we now understand have a relatively thin or even non-existent barrier. So these are areas where the brain needs to be able to sense from the bloodstream, like the circumventricular organs, areas where it may be easier for inflammatory signals from the body to get into the brain.

And you have kind of the overt things. For example, if you have a traumatic brain injury, you are damaging your blood-brain barrier and inflammation can kind of more rapidly get through and influence the brain. So the sum total of all this would suggest there are a number of ways in which systemic inflammation can reach into the brain and influence brain inflammation. It’s not a one-to-one though. And by that I mean you may have a elevation in a certain inflammatory cytokine in your bloodstream, but not have that in, let’s say, your cerebrospinal fluid. So it’s not exactly a one-to-one. You can have elevation in lipopolysaccharide, which gets into your bloodstream. It doesn’t mean that it all gets into the brain, but it can have a much bigger response if it activates your microglial cells than if you had other inflammatory stuff in your bloodstream. So all that is nuance. But the bottom line is to understand that systemic inflammation does have an impact on brain inflammation. It’s not one-to-one, but it is significant.

So any systemic inflammatory condition, and we could say both in terms of acute inflammation, so again, I mentioned sepsis, but these people who are very sick in the ICU, we know that a huge percentage of people in the ICU experience delirium. Delirium is correlated with elevations in inflammatory molecules in the blood. So there’s obviously a very significant interaction between systemic inflammation there and brain inflammation. But for most people, and most of the time what we’re talking about is chronic low-grade inflammation having a effect on brain inflammation. And so we’ve talked a lot about the inflammatory connections. I just bring up two metabolic connections, the immuno-metabolic. By that I mean that when we have chronic long-term inflammation in our bodies, that can damage metabolism or be a function of metabolism, and that can then lead to issues with brain metabolism or brain immunity. So there’s lots there. I think if I was doing the diagram here, it would be a little bit clearer, but just to understand that what happens in the brain is a reflection of what happens in the body. It’s not one-to-one, but it is significant.

Evelyne: I’m glad I asked the question because that was one of the most comprehensive answers I’ve ever heard. And I actually when we have this recording, I want to go back and watch it a few times and take notes. That was amazing. Something you said in there, I don’t think I’ve heard this before though. I do forget a lot of things, but about short chain fatty acids, you said strengthening the blood-brain barrier.

Dr. Austin Perlmutter: Right. So there’s some data there. It’s mostly pre-clinical, but yes.

Evelyne: Huh. Very interesting. Okay. So let’s get into some of the biggest triggers of neuro-inflammation and then also talk about some solutions. You already mentioned sleep, and I was going to say before when you were talking about sleep, I’m like, oh my gosh, all the new parents, I have some friends right now who have newborns and there’s just no sleep.

Dr. Austin Perlmutter: Well, let me just talk about that for a second because this is something that actually comes up relatively often when I’m having these conversations with people because they will say, look, you said that sleep is super important, but I’m a night shift worker or have little kids or I have insomnia and so I don’t like what you’re saying basically, or tell me something I can do to offset it. And I’m going to kind of take a position on this, which is to say there are certain things that are just true in the science. And so having a kid and not getting good sleep is bad for your health in the sense that the sleep deprivation is not helping your brain. And in the aggregate we do these things because hopefully they’re net positive. Right? So when I was in medical training, my sleep was awful. We would do a week on nights and then a week on days, and then by the time you got through that, you had almost no quality sleep because you were always trying to catch up.

But I did it because it was important training and it was because it was helping me to basically complete my residency and see the full spectrum of what was necessary to accomplish that part of my life. And so I think that the point I’m trying to make here is perfection is not the goal with any of the things that we’re going to talk about here. There is no scenario where perfection even makes sense because in order to exist in the world, you’re always going to be trying to do things in a good way for your health, but also in a way that allows you to move forward to have the life experiences. Being on a plane and being jet lagged sucks. It’s not good for your sleep, but the experiences that you have because of travel are a net positive often.

So as we jump into what can you actually do about this, the point I would just bring up is to say this is not a question of living in a hermetically sealed bubble and having eight hours of sleep each night and making sure that you’re only eating the most non-toxic foods, exercising for an hour each day. I think many of us have seen a gentleman named Brian Johnson, he’s a very wealthy guy. He spends $2 million a year investing in his health and he’s doing an amazing thing to show us what is possible, but we also see if you follow him that it’s not sustainable for the average person. So the point is there’s a lot of stuff that is true in science, but for real living people, and this is why a great practitioner is such an asset, we understand that it’s about finding ways to map the science onto an individual’s goals and actual life experiences.

Evelyne: Yeah. Absolutely. So let’s dive into what are the top causes of neuro-inflammation?

Dr. Austin Perlmutter: Yeah. So I would kind of say that this is also bundled with what are the things we can do about this. You know, I think there are many causes or many things that contribute to neuro-inflammation, and then there are many things that we can do to help decrease it. But the most interesting of these are the overlap in the Venn diagram, so things that people can understand that you can tell your patients about this is a risk factor and here’s what to do about it. There are certain risk factors, for example, climate change. Right? So we know that extremes of temperature are not good for our bodies and our brains, but I’m not going to tell everybody they need to move to the most perfect part of the world because of that. So the key here is to find the aspects that are both important in terms of risk factors and there’s something to do about it.

And so in this vein, I’ve been promoting something called the Six S approach, and these are six things that both contribute to neuro-inflammation as well as, I should say, disordered brain metabolism and impaired neuroplasticity, which are two other major drivers of neurological dysfunction and that we can do something about. So let’s start with stress. Stress is the first of the six S’s. I always say that stress is not something to be removed. It’s something to be mitigated because I think I am definitely somebody who has messed this up telling people, hey, you shouldn’t be stressed. It’s just insane. Life is stress. If you’re not stressed, you’re never going to get off the couch. Stress is the delta between what you’re doing now and what you think you should be doing or what should be different. We need some of that. At low levels stress is actually motivation. Right? So stress is necessary, but chronic and uncontrolled stressors are quite caustic to our bodies and increased neuro-inflammation long-term. So there are a number of mechanisms we could talk about here.

The bottom line is that everyone needs to be proactively taking steps to mitigate the stressors in their lives that can’t actually be solved for. I mean, a great example here would just be the news. Right? So if you watch the news for multiple hours of the day, you will be perpetually stressed. And the reason for that is because the news preferentially selects for things that induce stress because stress is so primal to humans because it is an existential threat, meaning our brains would prefer to stay alive than to be happy. So if you give the brain the option of either doing something that might keep you alive or caring about something that might keep you alive or caring about something that might make you happy, it’s always going to pick the thing that’s going to keep you alive, which means we are always paying attention to the negatives, to the scary things in the world. The news preferentially puts negatives and scary things out because it knows that’s what’s going to capture our attention.

And this doesn’t mean we shouldn’t be paying attention to what’s going on around us, but it does mean that there is a threshold in between becoming informed and simply becoming upset. So it’s paying attention to those types of things. Here’s my top tips though overall for stress. First one is mindfulness meditation. I don’t care personally if it’s a yoga practice or breath work or you just sit and look off into the woods for 10 minutes. There’s different degrees of evidence for all sorts of meditations, breath work, et cetera. But for most people, I think the most important thing is to dedicate about 10 minutes as a starting point to doing some of the debugging and space creation that comes from one of these practices. Additionally, movement is an anti-stress intervention. Any sort of nature exposure, I know that’s not always the top of the mind for people, but as doctors, as medical practitioners, we need to be writing more prescriptions for nature because nature exposure is a medical intervention to help decrease stress. But most people just think of it as a trivial, hey, I happen to be outside.

It’s shown from research that 20 minutes of nature exposure once a week is enough to decrease salivary cortisol. So I really think this is something that we should be talking about more. There’s a lot that could be said about social media, digital devices. I won’t get into that into too much detail, but I do think that is a major source of stress in most people’s lives and finding ways to mitigate that is important. And then, of course, finding professional help, always significant, especially if a patient or if you are experiencing significant psychological distress. But bottom line here is to understand that chronic psychological stress is a neuro-inflammatory stimulator and therefore we need to take steps to decrease our chronic psychological stress, and there are many different steps that we can take. The key is just to take at least a couple of them. So that’s one of the successes. Based on this timeline, I guess we’ll be here for a little while longer. Should we jump into the next one?

Evelyne: Yes. I would love to. That was great. Thank you.

Dr. Austin Perlmutter: Okay. So this is the dietary one. And my take on diet is that most of what people are hearing about is really unhelpful because people arguing over the stuff that doesn’t matter that much, they’ll be saying, oh, well, lectins are really the argument where most people are just still going through a drive-through restaurant and ordering absolute junk food. So I’m a big proponent of saying we need to just try to find ways for people to eat real food more of the time. With that said, I think that many people need something to target. And so while I think a Mediterranean or a MIND pattern diet is absolutely the most substantiated diet for better brain function, for talking with people, patients, even in ourselves having a target, and I think that target should be sugar. And so the reason I would say this is because when you look at the pros and cons in terms of various dietary nutrients, sugar has the most data to suggest that it is kind of unhelpful and probably unhealthy and contributing to metabolic and neuro-immunological, in this case, neuro-inflammatory diseases.

Now, I want to be careful here because sugar is important, and specifically circulating glucose in our bloodstream is the primary source of fuel for our brains. So this isn’t to demonize sugar as something that we don’t want in our bodies. I’m specifically talking about added sugar in our diet. And if we’re going to be even more specific, I always say that the start of this is to look at where we are taking in sugar in liquid form. Whether you are an integrative doctor, a conventional doctor, or anything in between, I think it is pretty much explicitly clear that sugar sweetened beverages provide no health benefit whatsoever, and I would say of any food have been most strongly correlated with risk for brain dysfunction and for metabolic disease and for immune dysfunction. So I think we can argue over diet with added sugar.

I do recommend that people cut back in general on anything with added sugar, not only because the sugar is an issue, but usually because it’s a great surrogate or kind of a proxy for telling us that this is a highly processed food, which by the way has been linked to worse overall and brain health. So I think that the step here would be to say trying to mitigate the effects of added sugar and in particular added sugar in sugar sweetened beverages as top tier intervention for improving brain health and decreasing brain inflammatory risk. So I do think cutting sugar sweetened beverages completely out of our diets is the right way to go. I think if people are looking for alternatives, Stevia, monk fruit, allulose, are kind of my current running top of the list in terms of relative, I guess, risk-benefit ratio. I think, two, if you want to take it a step further, certainly reduction of highly processed foods that are carbohydrate rich, so all the cakes, cookies, all those usual things. There’s some data suggesting that these are also not a good thing for overall health and for neuro-inflammatory risk.

But the other things that I would recommend people do would be to increase fiber intake. This is a good intervention for a number of reasons, but it can help to blunt the effects of this dietary sugar. And then the area that I’m involved in researching right now is understanding how certain dietary components found in plant foods, specifically polyphenols, things that typically make foods bitter can actually have a role on immuno-metabolic pathways. And so if a person is saying, okay, so I’m going to pull out the sugar, or I just want to start doing things that can help mitigate the effects of the sugar, I think that increasing polyphenolic intake, which you can get in coffee and tea and spices, and this plant that we’re researching called Himalayan Tartary Buckwheat. I think that is also a good tip. But coming back to the cornerstone of this, as we look at diet, it is certainly overall dietary quality that has the highest correlation with brain health outcomes. And I think it’s helpful to be able to tell people about something specific to target. In this case, I would go after sugar.

So that is, oh, one other thing I’ll say on that front, I am a proponent of the CGM, the Continuous Glucose Monitor. And the reason for that is that right now 10% of Americans have type two, mostly type two, but just have generally diabetes. That’s a big number, but 40% of Americans have pre-diabetes and pre-diabetes is an absolute risk factor for developing brain diseases and for inflammatory risk. And so how do you know that you have pre-diabetes? Well, yeah, you can get your A1C and your fasting blood sugar, but I think for many people, getting some actual data to understand how their blood sugar changes over the course of the day, which a CGM provides, is really helpful. So I’m a big proponent of trying a CGM. You do need a prescription for it at this point, but I think it is one of the best biofeedback mechanisms available to the general public right now along with HRV to tell us about what is happening in our bodies in real time. So those are some considerations around sugar. Shall I keep going?

Evelyne: Well, I agree with you. I think that’s great around the CGM. I actually had a question about the polyphenols because I’ve seen that you talk about these a lot and what I find interesting is that a lot of the time when we talk about polyphenols, we think of them in the context of antioxidants and how they work in that way. But can you just expand a little bit on polyphenols in the context of the immuno-metabolism?

Dr. Austin Perlmutter: Yeah. That’s a good question. So when I learned about polyphenols in training, it was simply exactly as you said in the bucket of antioxidants. And so polyphenols, just as background, 8,000 plus molecules, they occur naturally in plants and when animals consume them, they actually, there are some of them in animal products, lower levels. Polyphenols are used by plants to signal. So polyphenols are produced by plant roots to bring microbes in and to defend against microbes to protect themselves against UV radiation, temperature fluctuations. So they have all these signaling capabilities in plants and they’re actually involved in populating the plant microbiome, which is really interesting. When humans eat polyphenols, which we consume again, primarily when we consume plant-based foods. They’re especially high in colorful foods, in spices, in coffee, and tea. The belief has been that because of the chemical structure of the polyphenol, so anybody who remembers organic chemistry might remember that you have these phenol rings, these hydroxyls that are attached to these rings. That allows them to have an antioxidant functionality, but there’s really not a lot of data suggesting that that’s how they work in humans.

And the reason I would say this is when you give somebody potent antioxidants, so let’s say vitamin E, you don’t necessarily see that everything gets better. So it’s not as though that person’s only issue is that they have too much oxidative stress and that by pouring antioxidants into a human, you resolve that problem. What we see with polyphenols instead is that their effects are many. So one is they actually change our microbiome. When we look at some recent data, we see that polyphenolic composition actually modulates the microbiome, so they effectively function like prebiotics, which is super interesting. The other piece of this is that most polyphenols, 90 plus percent, pass through the small intestine and reach the large intestine prior to being absorbed. And that’s because the state that they’re in plant-based foods doesn’t allow for them to be pulled through the gut lining. So that means these polyphenols hit the microbiome and the microbiome can actually metabolize these polyphenols and create new metabolites. And some of those metabolites are actually absorbed by humans. So this means that they not only change the microbiome, but are changed by the microbiome.

And then the question is what do they do in us? So again, not only do they change the microbiome, which has a number of impacts for our health, but when we absorb these polyphenols, what they appear to do is influence the immune system, influence metabolism, and maybe most interestingly, polyphenols may change DNA expression by modulating epigenetics, which is the domain of research that we’ve been focused on in Big Bold Health. So connecting these dots here, it’s just a totally different conversation around the role of different foods and human health because what we’re saying here is that the polyphenol composition of a food which is influenced by the quality of the soil, by the microbiome of the soil, by the heat and the UV radiation that plant received, basically the health of the plant influences our microbiome, influences the way that our DNA is used. So it in essence takes us to a place very quickly of understanding that we are part of a larger system of data flux between soil, between plants and between animals and humans.

And that this idea we’ve had for so long as to a human starts and ends where their skin is, and all we need is just to get the macros and the micros right, and we’ll be healthy is really not all that accurate, specifically because we now see that populations consuming higher levels of polyphenols may be protected against brain diseases and live longer lives. And so we’re seeing a number of companies focusing on polyphenols as cornerstone to longevity protocols in particular because of what I just described, that they have effects on the immune system, that they can modulate metabolism and they can influence epigenetics. So there’s a lot more I could say about this. I think that’s probably more than sufficient for what people are interested in, but just to understand that there is so much more in the universe of what plants are giving to our biology than just the basics of fats, carbs, proteins, and then vitamins and minerals.

Evelyne: This is absolutely fascinating. I love it. Plants are so cool, and you brought up the soil. I think that’s so important because it’s something that we’ve lost in American farmland. And, yes, we talk about regenerative farming, but it’s not being done at a large scale. So that’s a concern. And maybe as people start caring about the health of our society, about our people, and our planet more, maybe there’s some of that that can be reversed. I don’t know.

Dr. Austin Perlmutter: You would hope.

Evelyne: Yeah.

Dr. Austin Perlmutter: I think the re-conceptualization that we need to have, and I guess it is a re-conceptualization because this is definitely the default state up until relatively recently in human history, is that resilience and health comes from diversity of the ecosystem. And so while there has been this ideation, I think especially in western medicine, to kind of compress and consolidate things down to specific receptors and specific drug targets, the reality is that humans, like every other species on the planet, thrive when there is diversity and in the ecosystem around them. And so to think, hey, humans are just going to eat at this point, it’s wheat, corn, soy, and rice that make up the majority of our calories, that we’re just going to eat these foods, especially in a highly processed format, and then we’re just going to sprinkle in some supplementation with some zinc or maybe some magnesium, and we’re going to be healthy, it’s insanity.

Because if you get to any level of comprehension regarding the interactions between the soil and the plant and the animal and the human, we recognize there’s no scenario that is, I think, healthy where humans exist in a world where all of these other systems are unhealthy. So I think that polyphenols are one part of that story because it turns out that organic and regenerative methods significantly increase the polyphenolic content and diversity of what is found in our food.

And this makes sense because if you take a plant and you put it in a place where it doesn’t have to kind of do anything to survive or it doesn’t have an interaction with the soil microbiome or it’s being doused with pesticides and herbicides, so it never really has to create the pathways, activate the genetic pathways to produce the molecules to fend off these threats, you’re just not going to get the same molecular composition of the plant. And so yeah, you could look at it and say the calories are the same. It has the same amount of fiber. It has the same amount of fat. But when you start to look at some of these other pathways like polyphenols, you recognize that it’s not the same. Right? It’s not the same plant. And similarly, the animal that eats that plant is not the same animal.

Evelyne: Right.

Dr. Austin Perlmutter: I think people are far more invested right now in understanding how a feedlot cow is different from a pastured cow or a free-range cow or a pastured chicken compared to a chicken that is raised in a cage and how those things have different impact on human health and physiology. But it’s all part of the same conversation, which is when we lose access to the diversity of data that occurs in nature, there’s a whole lot more that we’re losing than just the ability to promote organic or something like that on a label in a store.

Evelyne: Yeah. Absolutely. Thank you for sharing that. So we talked about stress, sleep, and sugar. What are the other three? And I think I want to talk about smoke, but tell me what the other three are first.

Dr. Austin Perlmutter: Well, let’s do substances then before we do smoke. Substances is basically the idea to compress down a lot of information. Alcohol is a pro-inflammatory factor and it is correlated with dementia and it is correlated with mood disorders. And we’re an interesting time right now. Surgeon General just said, hey, by the way, we should be putting labels on alcohol saying it creates or causes cancer. So here’s my take on this. Alcohol consumption has differential effects on different systems. As a brain person, I will say that the data are not concrete that consuming a glass or two of alcohol a day is going to increase your risk for brain diseases. Actually, there’s some data saying that it may be okay to have a drink if you’re a female or two drinks a day if you’re a male in terms of risk for dementia. With that said, alcohol is a pro-inflammatory stimuli.

And if you were to, this is a hot tip for those of you out there in the clinical world, if you were to measure people’s inflammatory markers when they are hung over, what you can see is that the elevation in inflammation correlates directly with the intensity of hangover. So I would say in general, if a person doesn’t drink, I would definitely not start drinking as a health intervention. If a person does drink, then I would say choose beverages that don’t have added sugar per my prior point, and listen to your body in terms of understanding that if you’re hung over, that’s too much. Your body and your brain is not handling that, which is why it is screaming at you saying that is too much. Similarly, and this is probably more relevant for people who have more significant alcohol use, but blackouts and brownouts, memory loss, alterations and cognition are very overt signals that the alcohol you’re consuming or your patient is consuming is creating a risk for brain health. So lots of things there. One last tip here ’cause I know we already talked about sleep.

If you’re going to consume alcohol earlier in the day is better because alcohol destroys your sleep cycle. So if you consume alcohol right before bed, the nightcap, for example, that is going to disrupt your normal sleep architecture. And even though you’re unconscious, you’re still creating a lot of issues because you’re not able to go through the cycles of REM and non-REM sleep the way that your brain needs to, so you’re not going to be rested. And more importantly perhaps you’re not going to get those anti-inflammatory and metabolic regulating effects and waste removal effects that you’re supposed to get over the course of a good night of sleep. So that’s substances. So let’s jump into the one last of the successes before we get into smoke, because I know that’s one that we definitely want to talk about. And the last one before that would be sedentary behavior. And so this is not something that is completely novel to anybody right now, and this is what I would always say is I don’t think there are that many people out there in the world who are unaware that exercise matters for their health.

But what we have historically seen is a incredible prioritization of aerobic exercise for heart health. This has been a very successful campaign in the United States. Everyone knows that jogging is a good thing for their heart. What people don’t know and what they need to understand is that if we do not move our bodies, it dramatically enhances our risk for brain issues, and one of the key pathways, again, neuro-inflammation. So a study came out recently showing that people who walk a decent amount each day, around 10,000 steps, are at about a 50% lower risk for developing dementia. These are insane numbers.

Evelyne: That’s huge.

Dr. Austin Perlmutter: These are things that everyone needs to know. But the bottom line here for the sake of brevity is exercising is absolutely vital if your goal is to protect your brain for tomorrow and enhance your brain for today, and it’s not just about aerobic activity, it turns out that weight training is key to this process. And the reason is that when you lift weights, when you basically engage in resistance training, you produce molecules from your muscles called myokines. They had names like Irisin, Cathepsin B. Brain-derived neurotropic factor is actually a myokine. When you produce these molecules, they have both local and systemic immunoregulatory, metabolic and neuroplastic effects.

And so I would say just as a very brief pitch on this would be, yeah, you still do want to be getting at least that five days a week of movement. Ideally you’re moving every day, but as you do these protocols, remember to prioritize some resistance training because if you’re going to be exercising, engaging your large muscle groups which are in your legs with compound exercises is one of the best ways to actually compress the value of what you’re doing in the gym into a smaller amount of time. And really to make sure that you’re activating these molecules called myokines that are linked to better brain health, so that’s sedentary behavior. We’ve covered all, except for the last one.

Evelyne: I’m surprised you’re able to fit them all in. And I was actually going to ask you about myokines, and I did have, one thing I wanted to add on the substances is I haven’t had a drink now in over five years, and I’ve brought it up on the show before. We’ve done a podcast on it. And I noticed that my mental health is probably what changed the most. So I’m sure a lot of that was linked to brain inflammation. So I didn’t feel as many of the other benefits, I think, that people experienced, but that part was really big for me, so I just want to touch on that.

Dr. Austin Perlmutter: And I think real quick, let’s normalize that you don’t have to drink alcohol. I think there’s this crazy undercurrent of social pressure, especially in the younger years, high school, college, to say that you’re not cool if you don’t drink, and everybody is doing it and I think especially once you get into your thirties and beyond, you’re able to say, actually, I feel better when I do certain things and don’t do others. So just validating that it is a completely good, reasonable, and healthy thing to do, to set a boundary and say, I’m actually not consuming alcohol because I feel worse when I do.

Evelyne: Yeah. Absolutely. And thankfully, the conversation around alcohol is shifting so much too and more and more over the last few years, so that’s really encouraging. So let’s talk about the last one, smoke and air pollution. And as we are recording this this week, the fires are still raging in Los Angeles and thousands of people have lost their homes. To practitioners in LA who are listening, our hearts are with you. And I’ve been thinking about everyone in the area, and I’ve been thinking a lot about that air pollution part because it’s all over LA and Southern California. And I think about how that affects pregnant women and children and it’s just devastating to think about. So I’m curious if you can touch on briefly, how does air pollution actually drive microglial activation and then some things that we can do.

Dr. Austin Perlmutter: Yeah. The first thing I would just say is this is a really rough time for a number of people in the Los Angeles, the greater Los Angeles region, and I kind of feel like the last thing that they need to know is that there’s a risk for inhaling smoke. It’s kind of like telling people they should exercise. They know that exercise is important, and people who are breathing in smoke right now know that it’s not good for them. And so I think let’s just separate two things. First is if you’re somebody who’s being affected by this or have been affected by it, that’s just a real bad time. And what we can do is we can also look at what’s coming next. And so it is important for people to recognize that air pollution is one of the most, if not the most important, under-recognized risk factors for brain health issues in the world.

And so despite the fact the wildfires are a clear and present issue for health, for basically survival right now as we’re recording, people are losing their lives to it, we also need to understand that long-term, the bigger risk that people experience from air pollution is what is happening inside of their homes. And that is because people in the United States spend over 90% of their day in their cars, in their homes, in their offices, not outside. About 40 to 50% of the air pollution in our homes comes from outside, which means that the other 40 to 50, or I guess 50 to 60% is being generated by us. And that’s really key to this conversation.

So certainly in the context of a catastrophe like the wildfires that we’re seeing right now in Los Angeles or the wildfires that unfortunately seem to be the norm where I live in the Pacific Northwest year over year, then we need to be thinking about when that air quality gets to unhealthy levels, what we can do to decrease the amount of air pollution that comes into our homes, and to make sure that the air pollution systems that we have within our homes of purification are set up in a positive way.

But to really nail down some of the specifics here as to why it is such an issue, we, I think as practitioners and as people in wellness tend to focus very heavily on what we consume in terms of the diet that we consume, the nutrients that we consume, and I think that people in general have more appetite, no pun intended, for learning about food-based interventions because it gets to interesting stuff like cooking healthy meals or detox plans and all of these things that just occupy a lot of social interest because they trend on social media and they involve eating, which people like to do.

But we may eat, depending on who we are, let’s say five times a day or maybe more, but around that. We take 20,000 breaths a day and we are consuming all of those molecules in each breath. And so majority of what’s in your air is going to be nitrogen. You have some oxygen. You have some other trace elements. But what turns out to be so significant are all of these pollutants that are found in our air that over time are one of the biggest contributors to our risk for developing things like inflammation, metabolic dysfunction, early death, and even fertility issues, blood pressure issues, mood disorders. This research is not just kind of fringe. This is being published in the top tier medical journals in the world, Lancet, JAMA, New England Journal of Medicine. What we know is that air pollution is a massive risk factor for worse health outcomes. And one of the key mechanisms that links the consumption or the breathing in of air pollution with worse health outcomes is what it does to our inflammatory regulation.

And the reason for this is that air pollution and really the focal point of air pollution has kind of been these small particles, particulate matter, and in particular, these very small particles called PM 2.5s. They’re basically 2.5 microns or smaller, so about a fourth of the size of the thickness of a piece of hair. The reason is because when we inhale these PM 2.5s, these very small particles, they’re able to pass into the bloodstream and induce systemic effects in our bodies and in our brains. And research shows that when we inhale these molecules, it increases microglial cell activity in the brain. And we’ve seen this in research published in Toronto and Mexico City. They look at dog brains. They look at human brains, so this is a big, big issue. Now, again, similar to what I was saying before, people would much rather say, well, I’m going to eat some healthier food. I’m going to detox and not eat added sugar. I should be good to go. It’s much harder to say, well, what’s actually in my air. Right?

It’s tougher to say, I’m going to get excited about this because I can’t see it, so how do I know? And what I would say here is start from the expectation that you are breathing in unhealthy air. Because the reason is that the World Health Organization says that the majority of us are breathing in unhealthy air. This is the default state. So 70% of foods in the United States have added sugar, but over 90% of us are breathing in unhealthy air. And importantly, the biggest risk factor for breathing in that unhealthy air is the things that we are choosing to do in our homes, in our offices, in our schools, in our cars. So this is the key is that this is a huge issue for our health. And when we address, when we decrease our exposure, we can reduce risk for all of these health conditions. And again, I just wanted to share the spectrum here is air pollution exposure dramatically increases violent crime.

So when you look at a map of the United States and you map violent crime against air pollution, what you see is that as air pollution goes up, violent crime goes up. You can see similar issues with test taking scores and kids dropping when air pollution goes up. You can also see that exposure to air pollution increases issues with fertility. That when moms who are pregnant are exposed to higher levels of air pollution, their postpartum depression levels go up. So the range of issues that this relates to are so dramatic. So with all of that said, what an opportunity. If we improve the quality of our air, then we may be able to decrease our chances of developing heart disease, lung disease, dementia, depression. It is such an opportunity. So then what do we do about it? Let’s get right into the actionables. The first thing is to understand that if you live in a home, which most people do, that is indoors, the top source of air pollution is going to be cooking. Now, there was a lot of debate recently over gas stoves.

It became somehow a political conversation as to whether gas stoves were good, bad, or just some sort of a political stunt. It is true that gas stoves are going to be the most concerning in terms of off gassing certain molecules. So these are not necessarily PM 2.5s, but these are other basically gases in the air that are linked to worse health. So I have a gas stove. It doesn’t mean you can’t have a gas stove if you have the opportunity to switch to induction, I would say that’s a good move if you’re looking at it purely from the perspective of air pollution. But the more important move for most people is just to understand that when you cook, you need to vent your stove. So what you don’t want is smoke in your house. I’ll just make it very straightforward. If you see smoke in your house, that is a risk for your health. So if you are cooking something on the stove, if you’re boiling a pot of water and making some steamed broccoli, not a huge deal.

But if you’re frying a steak and it is sizzling up or bacon, that is a whole lot of air pollution. So if you can, you want to make sure to vent your stove top whenever possible. Additionally, you want to look for other sources of smoke in your home. And two of the sources that I like to bring up that people hate me for bringing up are incense and candles in the home. Incense is an incredibly concentrated source of indoor air pollution. It produces by gram of weight about five times more particulate matter than cigarettes. And the irony of the whole thing is that people use incense for the wellness benefits. And what they’re actually doing when they inhale that smoke, palo santo or whatever else it is you’re smoking in the house, is that you are increasing your risk for a host of medical problems. So am I here saying that we shouldn’t use incense? Yes. Or what I’m saying is that if you choose to use incense, you need to treat it as what it is. It is a concentrated source of air pollution. So don’t use it for long periods of time.

Don’t use it in a closed environment. Try to vent. Try to maybe use it in a room that has lots of windows. Point here being is that it is not something that you want to inhale. Say that again. You don’t actually want to inhale the incense smoke. That’s going to probably create some controversy. People don’t love me saying that. Take it one step further. Scented candles, not great. Scented candles are mostly made from petroleum derivatives, so when you’re burning them, just realize that’s what you’re burning. But the real issue here is that these candles not only generate smoke, but they also produce a host of molecules like volatile organic compounds that actually may be a risk factor for overall health and for brain health. It’s not as bad as incense. Let me be clear on that. So a candle is not as bad as incense. Incense is kind of by definition producing air pollution. That’s what you see when you burn incense. If you choose to use candles, I think it goes like this, standard candles, soy candles, beeswax candles in terms of the relative risks.

So standard would be the worst. Beeswax would be the best. And then if you are going to use a candle, again, same things apply. Ventilate. Limit your time. If the candle is smoking, you can actually trim the wick and that helps a lot. So there are little things there, but just realize that if you’re smelling a candle and it’s got ocean breeze scent or cinnamon apple, whatever, that’s usually a synthetic scent, and so it’s probably not a good thing. And on that, I guess this is the rant part of my podcast interview. Air fresheners are just garbage.

Evelyne: Yes. The worst.

Dr. Austin Perlmutter: Whether it’s the phthalates in it or the fact that you’re basically just inhaling a bunch of chemicals that are completely unregulated, there’s a reason why so many people have sensitivity to fragrances. And it’s not just because they’re sensitive people and they need to figure it out on their own. It turns out that sensitive people to fragrances or people in general who, like me, walk into whatever store in the mall it is, and they start smelling the potpourri and saying, hey, I’m not really feeling great about this, it’s your brain telling you that this is a dangerous signal because of what it does to our bodies. So I am in general, a proponent of removing any air fresheners from your car, whether it’s the little dangly pine tree or otherwise from your home, the sprays, Febreze, and these other brands. What they do is cover up scent by producing molecules that we should not be inhaling. And yes, there’s a whole bunch of different conversations about some maybe not as bad as others, but I would just say in general, I don’t recommend them.

Last things I’ll just say here would be open your windows if you can. Obviously, if you’re living in a wildfire zone right now, don’t open your windows. But if you have cleaner air outside the home than inside, which is the case for most people most of the time in the United States, keep your windows open. Use your HVAC if you have one. If you don’t have indoor filtration systems, I do think air purifiers are a evidence-based health intervention. And so to that end, there are a lot of air purifiers. Air purification is really a physics equation. As much as there are all these kind of fancy ionizing, UV, molecular distillation, whatever, filters and technologies. The bottom line is what you want is a unit that has the ability to suck the air through a great filter. So what you’re looking for is a clean air delivery rate that is matched to the size of the room that you’re using. And so good air purifier lines should be able to tell you that information. And one last tip since we’re on the subject, off gassing from furniture and off gassing from chemicals is a real thing.

So when possible to avoid leaving chemicals out in your home. If you’re doing home projects. Don’t leave your paints, don’t leave your other chemicals open in your homes. Keep those outside of your house. Press wood products then to have higher levels of off gassing, so a tip here would just be to buy used furniture when you can. I think that’s actually a very sustainable intervention for most people in general. But new furniture tends to be much higher in kind of the off gassing, which is something that if you can, is worthy of avoiding. So that’s smoke. There’s a lot to be said. Again, just if you’re somebody who’s experiencing one of the issues from the wildfires right now, a lot of these things are kind of academic. They’re not your top concerns. But as we’re looking long-term as to the things we can do to improve our respiratory health, our cardiovascular health, and especially our brain health and decreasing risk for inflammation, air has to be at the top of the list.

Evelyne: Thank you so much, Austin. That was a very, very comprehensive overview of everything. So thank you. I do want to wrap up with our very rapid fire questions that we ask every guest. Number one, what are your three favorite supplements for yourself?

Dr. Austin Perlmutter: Yeah. Number one right now is creatine monohydrate, five grams a day. We can talk about this at length, but specifically for the brain health benefits, I think it is just, I personally think it is one of the best things that a person can do from a mechanistic and an evidence-based perspective for brain health. Two is going to be, I’m a big fan of kind of an all-in-one daily protein type shake. Now there’s not actually much great data suggesting that daily protein shakes do as much to build muscle as maybe some people think. But what I do believe is that for people who are trying to work on metabolic health, it’s a great way to bring in some high quality supplemental nutrients and potentially to replace what would otherwise be an unhealthy meal. So for me, it’s kind of a cornerstone of when I’m working, I don’t have time to make always a super healthy lunch, and instead of going to the store and getting a sandwich, I will actually do a protein mixture. I’m always a fan of food first.

But for travel and for other scenarios like that, I think protein powder, that includes also getting a good dose of bioactive vitamins and minerals, ideally polyphenols too, is something that I do basically every day. For the third one, I mean, I guess that’s a little bit of a toss-up. So magnesium is a good one to put on the list. A lot of people are magnesium deficient. We can talk about different forms of magnesium and which ones have the best efficacy in the brain. But we’ll just go with the tried and true and talk about omegas. So omega three fatty acids, I’m sure listeners know all about this. I won’t go into the details. But in terms of immunoregulatory potential, what is interesting is that it’s not just the omegas, specifically the EPA, DHA, and DPA, but rather the pro-resolving mediators that are secondary products of metabolism of those omegas. So what I would say is whenever possible you want to optimize nutrition through diet. And so for me, that looks like trying to eat salmon, mackerel, and other fatty fish between three and four times a week.

If I’m not able to hit that, I do think that supplementing with a high quality omega three product does make sense. There are a number of variables you want to consider there, not the least of which is where is it sourced from? Because if you think about the quality of what an omega three is, you’re basically consuming fat. And so fat because of the nature of its molecular structure, has a high chance of becoming oxidized or otherwise less valuable the more it’s exposed to the environment. So I think these are all things to consider, but the best study components of omega three supplements linked to overall and brain health are really going to be the DHA and EPA component of it with some emerging research suggesting that the pro-resolving mediators are also worthwhile. So those are just a few. And we could talk about if you saw the cabinet at this house.

Evelyne: I know. Right? I have them behind me. I have them in my room in different places in the garage. That’s just what we do. Right? We love supplements. Number two question, what are your favorite health practices that keep you healthy and resilient and balanced? Just a list, like your top three.

Dr. Austin Perlmutter: I am a very boring person when it comes to health. So I don’t do anything that somebody would say what a biohacker with the exception maybe of using CGM, caring about labs more than maybe some people. The top things, just some quick hacks. Sleep is always the top of my list of priorities in terms of value. So here’s some hacks. One is going to be that you should get a sound machine. It is always going to be louder in your room than you think. It turns out that if you hear noises, even if you don’t wake up, it decreases the quality of your sleep. Sound machine goes on, creates white noise, and therefore allows you to maintain a steady level of background noise and sleep better. So one of my main sleep practices is using a sound machine. When I travel, you can get an app on your phone or you can get a physical sound machine, white noise machine. I think that’s a really good tip. I exercise most days. I do weight training. I do aerobic conditioning.

Here’s another quick tip for aerobic exercise in the gym, I personally get super bored just walking on a treadmill. I don’t know if that resonates for other people. It turns out some machines have solitaire, which is phenomenal. So I will just crank up the maximum incline and I will put it at a pace where I’m not fully out of breath, but I’m definitely feeling it. And I will place solitaire for sometimes an hour and hike for many miles. So finding ways to make it enjoyable. And then the third piece, and this is kind of a very self-serving one, is I’ve become very invested in understanding air quality. So I measure air quality in my home. I have an air purifier that I’ve just been actually developing with a couple of partners for a company that’s going to be launching soon that gives real-time air quality measurements and has, I think, the best filters that exist.

So I’ve just gotten really interested in the air quality component and paying a lot more attention to how various aspects of air quality influenced my mood, mental state, you know, having been through several significant wildfires when I lived in Oregon and even some up here in Washington, I just think it’s so fascinating to see how our physiology is affected by the quality of the air that we’re breathing. So that’s a domain that I’ve become a lot more interested in, and I’ve been doing a lot more to take steps to improve it in my life.

Evelyne: That’s really interesting. Keep me posted when it launches. And last question, what is something that you’ve changed your mind about through your years in this field?

Dr. Austin Perlmutter: I actually into my mind about many things around health in terms of priorities, in terms of what is the role of pharmaceuticals, in terms of what matters most at a population level. I guess something that is a bit more recent, it has more to do with the muscle health. So I, for many years, was really recommending primarily aerobic conditioning for my patients and in general saying, look, you need to get outside. You need to get a treadmill. You need to just jog. Right? You need to get your heart rate up and you need to just basically aerobic condition in yourself for five days a week for 30 minutes a day. And I think the research around specifically brain health and resistance training and weight training has been so compelling. Now, I have always tried to prioritize muscle because in part, I grew up in a culture in Miami where it was just cosmetically or aesthetically a priority. And at University, University of Florida, it was a big deal. Everyone’s taking NO-XPLODE, not recommending that by the way, creatine whey protein.

And so I thought it was all just this kind of pursuit of maybe more vain measures of I just want to look good. But only in the last two years I’ve just been so increasingly convinced that gaining muscle, healthy muscle and maintaining it over our lives is, I mean, for many years we’ve all known important for longevity that sarcopenia is a huge risk factor for dying early in age-related disease, but specifically for brain health, that gaining healthy muscle and maintaining healthy muscle mass, which the best way to do that turns out, is to do resistance training and get adequate nutrition that this is fundamental for people’s long-term brain health.

So I have changed my personal mind about how I set up my exercise routines and prioritizing deadlifts and squats and leg press again, but I’ve just been recommending it a lot more too. I think it’s something that, especially people as I start to age just need to consider fundamental to their wellness routine. And I think women in particular have a higher vulnerability to thinking that it’s not important than men do, again, for some of the reasons I’ve already described, see it as related to masculinity and having the body type that other people care about. But it’s so much more than that.

Evelyne: Yeah. Thank you so much for sharing that. And I think that’s another thing in addition to some other things that we brought up today that is now part of the conversation and thanks to a lot of physicians who are talking about it, so that’s amazing. Austin, thank you so much. This was incredible. I’m so glad that you went to med school and that you pursued that path. I learned so much from you today, and I’m sure that our listeners did too. This was really good. Thank you.

Dr. Austin Perlmutter: Amazing. Well, thank you for having me.

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

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