What to Eat for Optimal Brain Health - with Max Lugavere | The Empowering Neurologist EP. 147

90% of what we know about Alzheimer's disease alone has been discovered only in the past 15 years, and so that's why I think there's this big knowledge gap, certainly in terms of the lay public, but also even within the halls of mainstream medical institutions with regard to the role that nutrition can play in brain health.

Well, hello everyone. I'm Dr. David Perlmutter. Welcome to The Empowering Neurologist. What we eat affects our brains. It affects our brains in terms of how our brains are working moment to moment, how our cognitive function is happening, how we're able to remember things, executive function, you name it. But the foods we eat also have a long-term play. They have a long-term effect in terms of charting our brains, Destiny as it relates to risk for various issues like senile dementia of the Alzheimer's type, for example. So we really have to pay attention to what we eat. We've certainly emphasized the value of eating appropriately for the brain many times on this program, and I think that we couldn't have a better guest to walk us through what it really means to have a genius kitchen than Max Lugavere. We've had Max on the program before. He is really one of my favorite citizen scientists. He has a very interesting story to tell that I'm certain he'll tell us today about what got him interested in this in the first place. But let me tell you a little bit more about Max. Max Lugavere is a filmmaker, health and science journalist, and the author of the New York Times bestseller Genius Foods: Become Smarter, Happier, and More Productive While Protecting Your Brain for Life, which is now published in 8 languages around the globe. He is also the host of the number one iTunes health podcast, The Genius Life. Max appears regularly on a variety of nationally syndicated programs, including The Rachael Ray Show and The Doctors. He has contributed to Medscape, Vice, Fast Company, CNN, and The Daily Beast, and has been featured on NBC Nightly News, The Today Show, and in the New York Times, as well as People Magazine. He's an internationally sought-after speaker and has given talks at South by Southwest, TEDx, the New York Academy of Sciences, the Biohacker Summit in Stockholm, Sweden, and many others. I've known Max for many years, and I'm always delighted to have him on the program. My friend Max Lugavera, it's really good to see you again.

It's great to see you. It's an honor to be here on the Empowering Neurologists Podcast. Thank you.

How are things going in your life?

Well, I'm very excited that my new book, Genius Kitchen, is out, which I've worked really hard on. I got to admit, I'm a little self-conscious being on the COVID It's the first time I've ever been on the COVID of a book, but I'm very proud of the recipes that it contains, as well as the nutrition and wellness guidance that is presented therein. I'm excited, and I'm excited to talk with you because, you know, I feel very lucky and blessed to call you a friend and a colleague, but I've been a big fan of yours for a while, and you know that I always support when your books come out. And I think we're very aligned in many ways, not least of which that we've both suffered personal tragedy at the hands of neurodegenerative disease. And so—

You know, I was just about to say, yeah, you come at it from a personal perspective, and I come at it from a professional perspective dealing with neurodegenerative conditions. And then you brought up the fact that we both shared the personal part. I hadn't— for a moment there, I had a little mind lapse forgetting what I went through with my own father. But for those of our viewers who don't know the Max Lugavere story, maybe you can, you know, give us some insight as to how we came to be here today talking about food as it relates to the brain. And a little bit about your journey.

Absolutely. Great place to start. So, I'm not a medical doctor. I started college on a pre-med track, but I ended up going into journalism. And I did that as a post-college graduate for about 6 years, working with some of the best of the best in the industry, where you're not trained like a PhD, but you are trained to investigate a given topic. And for me, my passions have always pulled me in the direction of health. nutrition and fitness, longevity, and the like. That's something that I'd always been passionate about, starting as early as I could remember, and those are the kinds of topics that I gravitated to during my tenure as an on-air journalist in the United States. And about 6 years into that job, I felt that I had learned as much as I possibly could have. In that position, and I left. I set out on my own, and it was then in my personal life that my mother, the person who I'm— I was the closest to in life, the person who I'd loved more than anything, started to display the earliest symptoms of what would ultimately be diagnosed as a rare form of dementia called Lewy body dementia, which is a progressive, incurable condition that feels akin to having Alzheimer's disease and Parkinson's disease at the same time. She was 58 at the time. She was somebody who anybody would describe as being in the prime of their life, full of zest and vitality, and yet she started to complain of brain fog, and she had a change in tandem with that to her gait. I had no prior family history of any kind of neurodegenerative disease, and my mom certainly wasn't an old person, so it's not that I could— it's not It's not like I could chalk up to what I was observing in my mother to an old person's condition. And so I was taken completely aback, and I had no answers, no framework with which to understand what it was that she was going through. And being the person that I loved most in the world, I felt really— I felt a very intense call to action to go with her to doctor's appointments, to try to understand what was going on, and to help her as her patient wingperson, if you will. And in every instance, I experienced what I've come to call diagnose and adios. And we've talked about that phenomenon a lot, Dr. Perlmutter. But unfortunately, when it comes to neurological conditions like Alzheimer's disease, the tools at a physician's disposal are very limited, and particularly with regard to these more rare forms of dementia. And it wasn't until a trip to the Cleveland Clinic in Ohio that my mom was prescribed drugs for both Alzheimer's disease and Parkinson's disease at at the same time. I Googled the drugs. I consulted Dr. Google, which is what any millennial with a data plan does in those moments. Phrases stood out at me, no disease-modifying ability. That was really the point at which I became fixated on trying to understand to the best of my ability what are the dietary and lifestyle factors that could have predisposed my mom to have developed this condition? What, if anything, is out there to point towards a disease-modifying dietary intervention, a therapeutic diet that may help my mom? Is there a lifestyle component to this condition that may help? In tandem with that, I discovered that these conditions begin decades before the presentation of symptoms, by some accounts 20 to 30 years. If you subtract 20 If you subtract— if you subtracted 30 from my mom's age at the time, you got me. And so realizing that I now had a risk factor, I became very interested in the notion of prevention. And so this is a journey that began about 10 years ago, and doing what I can to, to prevent this from ever happening to myself and to disseminate this information in an achievable and digestible way for others to follow suit is something that really has become my life's purpose. That's what has led me to becoming colleagues and friends with you and others in the functional medicine, functional nutrition space.

Well, you bring up some very meaningful points. The fact is that you were, or your mother was prescribed various medications, and you learned that these would not have an effect on the actual disease process. I'm going to expand that a little bit. Yes, we don't have any pharmaceutical Treatment for Alzheimer's or Parkinson's for that matter in terms of treating the disease. We don't have any pharmaceutical treatment that will treat high blood pressure, that will treat elevated blood sugar like we see in type 2 diabetes as well. There are medications out there that will treat the smoke, but not the fire. There are medications that will lower your blood sugar, that's for sure, that will lower your blood pressure, and people, many people take them, that's for sure, but Go off the medication and the disease is still there. And similarly, in the field of neurology, yeah, we have medicines that are useful to some degree, and Parkinson's can help people regain some control over their motor activity, and they're very effective at that. But they, again, are not addressing what's going on underneath, the pathology, the fire that's burning. Again, they're focusing only on the smoke. And that said, the other point that you brought up that I think is profound that people do not get, and that is that these diseases— Alzheimer's, other forms of neurodegenerative conditions— begin 20, 30, maybe even 40 years prior to their clinical manifestation. In other words, as it relates to Alzheimer's, we know that we can predict risk of Alzheimer's by looking at blood work, looking at inflammatory markers, One study was 28 years ahead of time predictive. Another study demonstrated that just measuring the size of the belly predicts Alzheimer's 34 years in the future. Not that that's a magic number, that just happens to be the number of years that that study predicted. So that these factors in, you know, the context of the fact that we don't have a treatment, for crying out loud, We've got to do everything we can to prevent that very disease for which there is no effective treatment. So gee whiz, I mean, as a medical doctor, generally I'd be raising my eyebrows right now and having a conversation with you thinking that you're going to tell me about food and the brain, food and Alzheimer's. And, you know, I think our viewers know that I'm being, you know, a bit sarcastic here because we certainly embrace that. We've had wonderful conversations with people across the spectrum, looking at nutrition. We've had the Sherzais and people like Dr. Bredesen, Dr. Hyman, many people in the space, and now delighted to have you tell us, A, that it matters and why it matters from your heart to all of our viewers. And then let's break it down. Let's talk about Genius Kitchen and the notion that the foods we consume today are going to play out in the future in terms of our brain's destiny. So where do we start?

Yeah, that's a great question. And also, I think it's, you know, my position in this is really as somebody who didn't come from any sort of preconceived notion about what it takes to nurture the brain. I mean, neurologists, Dr. Perlmutter, doctors in general are minimally trained when it comes to nutrition, as you well know. And then you take a neurologist, somebody who really is trained to look for answers within the organ of study, right? That, that, that the brain disease is— that the origin of brain disease comes from the brain. But now we're starting to look outside of the brain. We're looking towards the body. And 90% of what we know about Alzheimer's disease alone has been discovered only in the past 15 years. And so that's why I think there's this big knowledge gap, certainly in terms of the lay public, but also even within the halls of mainstream medical institutions. with regard to the role that nutrition can play in brain health. And so my only bias in coming towards this was that towards preventative health and also the acknowledgement that health literacy is something that we've all collectively outsourced and it's something that we've lost.

I think what you're saying is, hey folks, you don't have to go through what I went through with my mother. That's what you're telling people. And, you know, my response to that is, Hey folks, you don't have to necessarily go through what my countless patients or the 6 million individuals in America and their families are going through right now. You know, it's, it takes your breath away. It never goes away. It never gets any better. I had the opportunity several months ago to interview Ronald Reagan's daughter, who wrote a book about what it was like watching the former president of the United States decline cognitively and, you know, how it felt. And beyond that, what were the practical things they could be doing for the, you know, the former president of the United States. And so, you know, we would say, well, it's random. It isn't random. Mm-hmm. You know, people say, well, you know, your chances of having a bad outcome from COVID are random. No, they're not. Chances of having Alzheimer's disease are not random. If you choose to let your blood sugar get out of control, become metabolically compromised, gain a lot of weight, you're increasing your chances that if you live to be age 85, it's going to be 50/50 anyway. So, uh, a coin toss. Yeah, the toss of a coin. What you're going to be telling us, uh, is, is going to be very, very valuable. So Let's dig in. Where do we start as we enter the genius kitchen?

Food plays a huge role. I'm a big advocate of the consumption of whole plants and properly sourced animal products. I think that from the standpoint of the brain, omnivory is the most biologically appropriate diet to support optimal brain health. I like to talk about foods that I've identified as and called genius foods. Genius foods is not a scientific term, but these are the foods that repeatedly would stand out to me in the medical literature as being particularly supportive and promotive of optimal brain health and brain function and good mental health, I might add. Because as I was writing my books, I started to realize that the same steps that we can take that are going to batten down the hatches and protect our brains tomorrow, next year, and decades from now also improve the way that our brains work in the here and now. They boost executive function, they boost an aspect of our cognition called processing speed, which is one of the first features of our cognition to decline in Alzheimer's disease, and also boosts mental health. There's now this burgeoning field called nutritional psychiatry, which looks at how food affects mood. And so foods like— I mean, I guess we could start at the base of the genius foods pyramid. You could say you have avocados, which are a fruit and contain the highest concentration of fat-protecting antioxidants of any other fruit or vegetable. which is of particular significance to the brain because the brain is made largely of fat, but not just any fat. Fat isn't fat, Dr. Perlmutter, as you well know. Our brains are constructed of fats that are particularly vulnerable to a process called oxidative— oxidation, and ultimately oxidative stress, which is an instigator and driver of many of these conditions that we're talking about, whether it's Alzheimer's disease, Parkinson's disease. They can exacerbate preexisting conditions. in the brain. And avocados really are a powerfully protective brain food, a rich source of vitamin E, which we know is one of the most important fat-soluble antioxidants, carotenoids like lutein and zeaxanthin, which we've known for decades protect the neural tissue in your eyes, the macula. But we now also know that these same compounds accumulate in the brain, where they help prevent cognitive decline, they improve the way that your brain works in the here and now, There was a wonderful University of Georgia study that found that in young healthy college students that supplementation with carotenoids, these plant pigments called lutein and zeaxanthin, led to a 20% boost in visual processing speed. Avocados are enriched with these 2 compounds. I'm a huge fan of avocados. Then ping-ponging to the animal-sourced side of the table, I love to talk about grass-fed beef. Grass-fed beef is, I guess, one of my more controversial recommendations. But to me, it's a really wonderful brain food in that it provides a bevy of highly bioavailable micronutrients that we know are not only supportive of good brain health, but tend to be underconsumed today. So vitamin E, as I mentioned, you can find in abundance in grass-fed beef. You find a compound called creatine, which we know directly supports brain energy metabolism. So if you're feeling fatigued regularly, we know that creatine can help support optimal cognitive function. There are studies that have taken vegans and vegetarians who don't regularly consume creatine. Creatine is considered a carnitine nutrient. It's found only in beef and fish, so you don't find creatine in animal products. So vegans and vegetarians don't regularly consume creatine, and when given supplemental creatine, they see an improvement in their cognitive function. Which suggests that this is a vitally important nutrient for optimal brain function that we can easily find in animal products. Then grass-fed beef is also a pristine source of protein. Protein is a non-negotiable when it comes to metabolic health, when it comes to good brain health. We know, thanks to the Digestible Indispensable Amino Acid score, that animal protein is the highest that we find in nature with regard to protein digestibility and protein quality, thanks to an abundance of essential amino acids. There was a study, Dr. Perlmutter, that came out actually that looked at people who were at high genetic risk for developing Alzheimer's disease. What was the key characteristic that determined in this study one's risk by threefold frailty. And we know that dietary protein is important as a means of preserving our lean mass, our muscle mass as we age, which is crucial. So avocados, grass-fed beef, I'm a huge fan of dark leafy greens. We know thanks to this burgeoning field of research looking at the microbiome and helped— you've been one of the major tentpoles in popularizing microbiome research, Dr. Perlmutter, but we know that—

Tentpoles, I've never heard the term, but I get where you're going.

Isn't that— I mean, somebody who's like a torch carrier or something like that.

I've never been called a tentpole before, I want you to know. There you go. I'll accept it.

Yeah. Well, you've been one of the loudest champions for practical microbiome, the translational aspect of the research that's now coming out. And we know that a bowl of dark leafy greens provides powerful fuel for the gut bacteria that then churn out compounds called— referred to as postbiotics, like butyrate, which directly support neuroplasticity. Researchers out of Rush University actually found that people who consume a big bowl of dark leafy greens every day have brains that perform up to 11 years younger. So this is a rule that I think for anybody's genius kitchen Have a salad a day. Set that as a guideline for yourself. Research shows that people who do that have more youthful brains, which is a win-win scenario.

You use the term postbiotics, and just for our viewers, the strict definition of postbiotics means inanimate microbes and/or their constituents that have a positive effect on the health of the host. And so these are the products made by bacteria, the breakdown products when bacteria are recycled, provided they have a positive effect on the health of the host, meaning you and me. So we're seeing now this whole trend towards not just taking probiotic or eating probiotic-rich foods, fermented foods, but nurturing the microbiome with prebiotic fiber, and now the addition of postbiotics even to commercially available preparations to enhance their function. So now it's prebiotic, probiotic and postbiotic. And I'll tell you where the excitement is as a little bit of a preview. We now recognize that the functionality and the life cycle of our gut bacteria are highly influenced by viruses. We call these bacteriophages. The bacteriophages in the gut outnumber the 100 trillion bacteria by a factor of 10 to 1. And specific bacteriophages target very specific strains of bacteria. The viruses control the destiny of the bacteria such that— and they're floating around in us at all times— such that the— it gives us a new tool for regulating good versus bad bacteria, if we could ever figure what that— out what that is. But we know now that higher levels of certain bacteriophages, meaning the viruses in the gut, are associated with better cognitive executive function in humans. versus higher levels of other bacteriophages, and that if you take the fecal material from a human that has higher levels of the good viruses in the gut that regulate the bacteria, and you transplant that into a mouse model, its executive function, its memory function as well, will improve. So now we're looking at the gut virome as well as the microbiome that traditionally encompass bacteria. You know, the broadest interpretation for microbiome, of course, is all of the microbes. But when we start looking at the virome and we realize that we're going to have probiotics that contain bacteriophages on the shelves to regulate our gut bacteria, it's next-gen. I mean, we're, you know, we're Star Trek: The New Adventures. It's really quite exciting.

It is quite exciting, and we are just at the tip of the iceberg. And I think what has come to light is that by eating a broad array of whole plant materials— so I'm not talking about ultra-processed plant-based foods, but whole plants, the single-ingredient foods that you find in the produce section of your supermarket— you're nurturing the bacteria and maybe even the viruses, the virome, with a broad array of fibers that they need to survive. They need to survive. And with any one— You're right.

The viruses are sensitive to the foods that you consume. So now, we used to say foods change the bacteria that has a role to play in our health. Now we insinuate viruses. Foods affect the viral array, affecting the bacterial array that then has a role to play in our health. Again, that's to come. It's very exciting. And you know what? You got to be comfortable with it because Who knew? And who knew about the gut bacteria 10 years ago? We didn't. And now we get why we should eat plants, exactly what you're talking about.

Yeah. And I think plants play an incredibly important role in satiety as well. They provide dietary fiber, which not just serves as a fermentable substrate for our gut bacteria, but also absorbs water and helps us feel full by stretching the stomach. turning off the release of that hunger hormone ghrelin. I love to talk about, Dr. Perlmutter, the factors that make a food satiating, because today, in light of the research showing us that 9 in 10 adults have some component of metabolic syndrome, many of which suffering from obesity, by the year 2030, 1 in 2 adults are gonna be not just overweight but obese. I think it's really important to talk about how to use food as a tool for satiety. And certainly all of the recipes that I provide in Ingenious Kitchen are to maximize satiety while also maximizing nutrient density. But it's very empowering, I think, for people to know the 3 tools that they can look to. And one would be fiber, as I mentioned, because it mechanically stretches out the stomach, which fiber is actually not— it's not an essential nutrient. It's conditionally essential and we're seeing the powerful role that it plays in nurturing good gut health. But it's satiating because— not because we have an innate need for it necessarily, but because Because again, it draws water, it stretches out the stomach. It's also very good for lipid regulation. I'm a huge fan of the gel-forming viscous fibers that trap cholesterol in the gut. Fibers like psyllium husk, very beneficial. Not just used— not just a tool to stay regular, but actually really good for helping promote cardiovascular health. So fiber, fiber is crucial. The second factor that makes a food satiating is protein. We know that protein is the most satiating of the macronutrients, more so than carbs and fat, although fat does help slow digestion, so it can help prolong that satiety effect. But protein, as I mentioned, it's crucial to help grow and maintain lean mass. We see studies that people who consume more protein tend to have lower amyloid burden in the brain, which is obviously related to Alzheimer's pathology. And also foods that are rich in protein tend to be rich in myriad other micronutrients that we know tend to be underconsumed, and micronutrients that play an especially supportive role of brain health. Micronutrients like zinc, like vitamin B12. There was a study published by Stuart Phillips, who's a protein expert at McMaster University, who found that high protein foods and particularly animal sourced foods tend to contain. Micronutrients that are typically underconsumed. And not just that, but in their most bioavailable form. So this is a non-trivial point. And protein, we know, satiates our hunger. We can look to the protein leverage hypothesis. So leverage protein. If you have difficulty regulating your hunger, reach for high protein foods. Foods like Greek yogurt, grass-fed beef, beef jerky is a great snack. Yeah. Sardines, wild fatty fish, hard-boiled eggs. These are all incredible snacks and useful for assuaging our hunger. And then the third factor that makes a food satiating is its water content. You talk a lot about in your new book, Dr. Perlmutter, the value of hydration, which is so important. But I think it's important for us to remember that for a hunter-gatherer that didn't have access to bottled water and running faucets, That the second best place that they would find water would be their food. They would find hydration from the food that they would eat. And so when we are thirsty, sometimes our brains misinterpret that signal as hunger. And yet ultra-processed packaged foods, the kinds of foods that really now are at the foundation of the obesity epidemic, tend to be dehydrated. And the reason for that is that water, moisture, makes a— impedes a food's shelf stability. 'Cause it allows for the growth of mold. So if you take ultra-processed foods, they tend to be diluted of their protein content because protein is the most expensive of the macronutrients. They all tend to be some combination of carbs and fat, flour, salt, easily recognizable when you look through your snack cupboard. It's the chips, it's the, you know, those kinds of foods that tend to be hyperpalatable They tend to be low in protein. They also tend to be depleted of fiber, right? Because fiber is what you find typically in fresh produce, right? Fruits, vegetables, legumes, things like that. And then of course they're dehydrated. So if you want to be satiated by your food, if you struggle with problems with your weight, those are the 3 factors that I highly recommend seeking out instead.

I would add, You know, that basically protein is telling you that the hunting is good. It's telling your body the hunting is good, no need to, to keep eating, no need to store fat. And on the other side, I would say the most powerful food that we would consume that would tell us to keep eating, that inhibits leptin, that makes us want to eat more, is fructose. And as a survival mechanism, That was a good thing when we would have fructose in the fall when winter was coming. We'd eat as we'd eat more than we normally would, which is happening 365 days a year now with fructose consumption. But it was a survival mechanism because if we ate more, we would make more body fat and we would have a little edge. You know, we'd have this superpower. We had a little more body fat and we would then survive the winter, the time of caloric scarcity as a Hunter-gatherer, or even before that in our primate ancestry time. I learned a couple of things with this new book that I wrote. You mentioned about uric acid, and been watching some of the interesting comments on Amazon, and one of them was gave me a one out of five. It said, "Oh, it's obvious the vegetarians got to Dr. Perlmutter." You know, because we talk about a you know favoring a more plant-based diet, though we have recipes with eggs. And chicken and halibut and you name it. But that person didn't obviously see that. And the other is the, you know, the pushback on looking at evolutionary biology. I wasn't expecting that. I mean, I think we get to learn a lot about, you know, how we have the type of physiology that we do have that you're referring to right now. How these things like protein are satisfying and how things like fructose stimulate our appetites. Based upon the evolutionary advantage that it conferred. And boy, there's a bit of a pushback on that as well. And I'm, you know, I'm happy to be— to go with that and be there. But gosh, it can be so aggressive at times, that's for sure. So you have a lot of recipes. How easy are these to cook? I mean, where did you fall on complication versus ease of creation?

Yeah. So Genius. I wrote it to be a 2-in-1 book. It's a half cookbook, but it's not just recipes. There's a significant portion of the book that's dedicated to advice and providing people with a light so as to understand and be able to separate fact from fiction with regard to nutrition. So I break apart each food component. We could talk about some of those if you'd like, but animal products, plants, salt, water, dairy, eggs, fish. I go into detail with regard to each of those different types in terms of what to look for in the supermarket and what to try one's best to avoid without any dogma, recognizing that nobody's perfect and we all have different levels of access with regard to food. But the recipes really are meant to be highly accessible and utilize ingredients that are

Well, you mentioned salt, and, you know, almost always in discussions like this, that doesn't come up. It's usually about, well, we know refined carbs, highly processed foods should be avoided. Let's get more fiber, more color on the plate. But you bring up salt has no calories. So why would we think about salt?

Well, salt is— first of all, it provides sodium, which is a macromineral, meaning we need to ingest a relatively low amount of it. large amount of it relative to other trace minerals, for example, for good health every day. And our needs for sodium increase or decrease depending on various lifestyle factors. So for people that are on very low carbohydrate diets, their needs for sodium increase. A lot of people that will abruptly transition to a low carbohydrate or even a ketogenic diet without acknowledging the increased needs that their bodies will then have for sodium. experience what has been called the low-carb flu. But by just adding a little bit more sodium and other electrolytes to your diet, you can avert, for all intents and purposes, that unpleasant feeling that's associated with the transition to a low-carb diet. Also, people who sweat vigorously, which is actually an important thing to do, whether it's via sauna or vigorous exercise, replenishing electrolytes is really important, and sodium is one of the most easily lost to our sweat. So bringing salt back to the table I think is really important. And it's also— its role in the kitchen is not to be underappreciated. In fact, professional chefs, when they look at home chefs and— one of the key differences is that home chefs tend to undersalt their food. And we've been told for decades to avoid sodium for fear of what it does to our blood pressure. Right. However, it's important for people to recognize that only 11% of the sodium that your average person ingests comes from what they add to their food via their own salt shakers or what they add to their foods when, when crafting various recipes. The vast majority of sodium that your average American consumes come from packaged processed foods, shelf-stable foods, fast food, and restaurant food. And so once you start to eat at home more, which is a powerful leverage, point of leverage in and of itself, which we could talk about, and they start minimizing, reducing their consumption of these ultra-processed foods, then where they're getting their sodium from, once again, like it has been for the vast majority of human history, becomes a concern. And then you take foods like cruciferous vegetables, you know, Brussels sprouts, broccoli, cauliflower, Some of the healthiest foods in the supermarket are simply not palatable unless you add salt to them. So bringing salt back to the table, I think, is very important. And again, make some of our healthiest foods palatable, which is crucially important. I grew up in a family, my mother was very good at seasoning vegetables, but I think actually one of the major reasons why you see so many people adopting these carnivore diets is because they grew up, my hypothesis is that they grew up not eating vegetables that were made very well. And so I love to provide— I've got a number of recipes in the book, some of which are fully plant-based, that integrate vegetables. And the seasoning, I think, is— it plays a really important role. It's also a low-calorie way to increase your enjoyment of food, right? And it's one of the— if you take something like a ribeye, a ribeye is actually a piece of meat before you cook it. It's the adding salt to it that makes it a steak. So we can't underappreciate the value that sodium, that salt has in the kitchen.

Well, I would tend to agree that we enjoy our salt. I would simply warn people though that if they are going to be salting their foods, they've got to be sure that they're hydrating along with that. Because what we don't want to do is add so much sodium that we tick up the serum sodium, which lets the body believe now that it's dehydrated. What does that do? That's a signal to make fat. So we've seen the, you know, lots of research that correlate the addition of salt to risk for obesity, addition of salt to risk of diabetes, and certainly to risk for hypertension. Not that all people are salt sensitive, but there are other mechanisms involved. We know that when the sodium goes up, as in after a very highly salted meal, it triggers the body to produce its own fructose. And that is a signal to make fat through uric acid. So if people like salt, I think that they can use it, but I would say you've got to dilute it after the fact or during the consumption by drinking lots of water. That will keep the serum sodium level from elevating and help offset those downsides. So, you know, people do love their salt, but it is correlated with some other things that You know, getting back to our original thesis here, that may play a role as harbingers for cognitive decline and dementia. So we've got to think about that.

Well said. But I think it is important to recognize that the number one source of dietary sodium in the standard American diet, it's not processed meat, it's not canned foods, it's bread and rolls, Dr. Perlmutter. But I can't tell you the last time I heard a dietitian tell patients to avoid bread and rolls, they usually will go, will lunge toward the salt shaker. And again, only 11% of the sodium that people ingest comes from salt.

How about bubbly water?

Somehow, yeah.

Carbonated water, it's carbonated, but it's sodium bicarb. There's sodium in that, which is why you drink a lot of sparkling water and it doesn't really quench your thirst, does it?

No, yeah, you definitely find a lot of sodium.

There's sodium, that's why.

Absolutely.

I want to explore how much sodium that actually has. Maybe I'll write a blog about that. So we talked about fiber and the need for fiber and just as to make the point that there is no fiber in any animal product, therefore that's an argument in favor of eating more plants. You mentioned eggs. In my time growing up, or as my dad would say, when I was your age, When I was your age, if you ate eggs, your kids would be born naked. Something horrible would happen to you. It was the worst thing you could possibly do. And to this day, go to a restaurant and ask for the breakfast— for breakfast, look at the menu, they will have the egg white omelet, right? Right. That's a thing. So what do we need to do to convince people that there are things in eggs like choline, for example, That are really good for your brain and really good for your health in general and not heart-threatening.

Well, Dr. Perlmutter, I want people to think about eggs. I want them to consider eggs a cognitive multivitamin because that's essentially what an egg is, especially with regard to the yolk, which is custom designed by Mother Nature herself to contain everything required to grow and sustain a healthy brain. It's no wonder that egg yolks are rich in cholesterol because the brain is rich in cholesterol. 25% of the cholesterol in your body is housed in your brain. Now, that's not to say that you need to consume dietary cholesterol for better brain health, but it's no secret that an egg yolk— it's no surprise that an egg yolk is rich in cholesterol because it contains a little bit of everything required to grow a brain, vitamin B12, zinc, you've got an abundance of choline. In fact, an egg yolk is the top source of choline that I'm familiar with. Interesting. in the modern food environment, and about 90% of adults don't consume the adequate intake for choline on a daily basis. Choline is important. It provides the backbone for the phospholipid bilayer, which supports neuronal health so that your brain cells can communicate with one another. It provides the precursor molecule for acetylcholine, which is an important neurotransmitter involved in learning and memory. My mother had a drug that was prescribed for her dementia that attempted to raise levels of acetylcholine in the brain, right? But we know that we can't— our brains can't create something from nothing. The responsibility is on us to consume the precursor molecules for our various neurotransmitters. Choline is one of them, right? Protein provides, for example, tryptophan, which is a precursor to serotonin, which is an important neurotransmitter implicated in healthy mood and executive function. So egg yolks really are a wonderful food. We know that dietary cholesterol has no long-term impact on serum cholesterol, and so I implore people to make regular use of eggs. It's no wonder that in the culinary world, people are constantly trying to put an egg on things that are that typically wouldn't have an egg on them just because they're so delicious and they provide so much satiety and so much nutritional value. I've got a number of wonderful egg recipes in Genius Kitchen. And I think it's interesting that the egg is where life begins. It's— and life is so diverse, right? There's— it's no wonder to me that there are so many ways to utilize eggs with regard to cooking. They're very economical. They're super cheap. Pasture-raised eggs are an abundance of brain-protecting antioxidants, but also even a conventional egg is still a health food. So yeah, I think eggs are a powerful food and they're definitely a staple for me.

So I had 3 today in an omelet that I made with kale from our garden. So fresh kale picked probably 2 or 3 minutes prior to getting into the omelet pan, 3 eggs, and I'm still here to tell the tale. You know, you mentioned something about your mother being put on a drug that was designed to actually increase acetylcholine in her brain. And, you know, it gets back to the so-called cholinergic hypothesis of Alzheimer's, as if the Alzheimer's brain, if it only had more acetylcholine, everything would be great. And the number one drug on the planet is based upon that hypothesis, and it's being prescribed, you know, to countless Alzheimer's patients in America and around the world based upon this flawed theory. A Dr. Richard Kennedy publishing in the journal JAMA, Journal of the American Medical Association Network Journal, published a meta-analysis of I think 12 studies, several thousand people, and he demonstrated quite convincingly that those individuals who do take that drug actually have more rapid cognitive decline In comparison to matched individuals who do not take the so-called magic Alzheimer's pill. And yet, you know, that's the standard of care that you should be giving that drug as a neurologist, and if you don't, there's something wrong with you and you're going to be, you know, brought up before who knows who because why didn't you prescribe that drug? Well, because it doesn't work and it's actually making people decline more quickly and violates the notion of primum non nocere, above all do no wrong. There's pushback, and, you know, we talked at the very beginning of our time together, you talk about how much education doctors get in terms of nutrition in medical school, and I had no training whatsoever. I kept waiting for that day, but it never happened. And I think that there is an active effort to steer practicing physicians away from any nutritional literature. Any studies that come out indicating that people who eat a diet that has more vegetables and good fats in it are at lower risk for Alzheimer's, people eating a more Mediterranean-based diet have a lower risk for Alzheimer's, the PREDIMED study, for example. I think that there's a— I don't want to sound like a conspiracy theorist, but I think there's an effort to keep us away from having that literature in the very top mainstream well-respected journals. We don't really see it. I will say one thing though that really caught my attention. It was in 2017, published in the journal Neurology, which is kind of the Bible of neurology. It's the— it comes from the American Academy of Neurology. They're the, the ones that say that you're a board-certified neurologist. And they wanted to determine what could they give, what is this magic or most validated thing you could give a person recommendation, what, you know, drug or whatever you could give a person who has what's called mild cognitive impairment. They're on their way to becoming fully impaired cognitively with Alzheimer's. What do you do as a neurologist? Here's that patient in your office. They looked at 14 different interventions, including the drug Aricept, which is what we were just talking about before, the cholinesterase inhibitor, memantine, all the drugs. They concluded that one thing is effective In slowing a person's risk for Alzheimer's or slowing their rate of decline when they have MCI or mild cognitive impairment. And it was a drug called exercise. As a matter of fact, getting your patient to do some physical exercise slowed their rate of cognitive decline. Is that considered mainstream medicine? It was published in our most well-respected journal, and yet, you know, Exercise and getting enough sleep. Who knew? And eating right. These are the pillars. You know, this is what Alzheimer's prevention is all about. And and yet, you know, there is no Alzheimer's prevention month, though there should be. We should do that, Max. And it really is. You know, it really calls to question the emphasis. The emphasis is live your life however you choose, and when you have a problem, we're here to fix it. And There is no fix for not just the problem that your mother experienced, but all the rest of those people, including my dad, who originally suffered through it, and then ultimately at the end stage isn't real— I guess they're not really suffering. They're fully unaware of what's going on around them. It's just all the rest of us who suffered, need I tell you? And so good on you for— Absolutely. For picking up. You know, for making the lemonade here. And now with your new book, Genius Kitchen, I mean, giving people, you know, a powerful leg of that stool. You know, it's the exercise, the sleep, and diet. And this answers, you know, 1/3 of all the questions already. So way to go, Max.

Thanks. Thanks, Dr. P. Yeah, I'd like to, you know, talk about something that might be a little bit surprising, but with regard to mild cognitive impairment, there was an interesting study that found that— interesting, it was actually a seminal study. It was called the SPRINT-MIND trial that found that for people with high blood pressure that were treated with a pharmaceutical to lower their blood pressure, they saw a significant and robust risk reduction for the development of mild cognitive impairment, which is pre-dementia essentially. But we now know, thanks to very high-quality meta-analyses, that exercise, plays a powerful role and is just as effective as drugs with regard to normalizing one's blood pressure. But something that, that is not quite as obvious is the role that antiseptic mouthwash can play in our blood pressure. And this is actually something that I do talk about in the new book Genius Kitchen. But there was a startling study that found that for people who frequently use antiseptic mouthwash— I'm talking about 2 times a day— every day, that they saw a doubling of their risk for hypertension. And the reason for this is that when we use antiseptic mouthwash, we're indiscriminately killing bacteria in our mouth that help ensure that the foods that we're eating are actually having a cardioprotective and a neuroprotective effect. So beets, for example, arugula— these, these foods are very high in compounds called Nitrates. And when we consume these foods and when we chew them, oral bacteria reduce the nitrate to nitrite. They convert nitrates in vegetables, in fruits and vegetables, into compounds called nitrites, which then enter the nitric oxide pathway, which helps reduce blood pressure and increase blood flow all throughout our bodies. And this is one of the reasons why arugula beets, dark leafy greens, all so great for us from a, from a, from the standpoint of cardiovascular health, which we now know the brain relies on, right? The brain relies on, on heart health. And so when we indiscriminately nuke the bacteria in our mouth that play a pivotal role in that pathway, we're increasing our risk for high blood pressure, and we cease to be able to derive a cardioprotective benefit from our food. For anybody listening to this who regularly utilizes antiseptic mouthwash, you want to make sure that you break that habit. Occasional use, especially when medically indicated, certainly not a bad thing. But this provides a powerful axis by which antiseptic mouthwash can actually contribute to one's predisposition to developing dementia, which is— That's right. Shocking, but true. I was actually in a pharmacy the other day, and I saw an ad for a big antiseptic mouthwash, well-known brand.

Yes, kills 99% of germs.

There you go. And what it was saying, it was saying that people with type 2 diabetes are at increased risk for periodontal disease. And it was saying, buy our product, especially if you're type 2 diabetic. But actually utilizing that product can contribute to one's risk for developing type 2 diabetes via that, that exact axis. Published in the journal Nitric Oxide, they found that people who frequently used mouthwash were at a 50% increased risk of developing type 2 diabetes, again through this pathway, because we know that nitric oxide is a powerful signaling molecule with regard to insulin sensitivity. So What you eat matters, but also oral care plays a large role in our ability to reap benefit from our food. And antiseptic mouthwash, by nuking the oral bacteria, can have a number of broad-reaching detrimental effects on our health.

Well, it's a very big story, especially when we look at a study that came out about a month ago It looked at medical records of about 6 million individuals and determined that men who frequent— mostly men, but people, mostly men, who take sildenafil, which is Viagra, a drug that increases the function of nitric oxide, had about a 69% reduced risk of Alzheimer's, to the extent that the authors concluded that maybe this is something we should consider. Because nitric oxide, as you mentioned, is important for allowing blood vessels to relax, more blood supply to the organs, the brain, the heart, the kidneys, etc. But also, you mentioned in passing that nitric oxide is important in terms of how insulin does its job. One of the ways that uric acid does so much damage when it's elevated is it inhibits nitric oxide that increases blood pressure. Decreases blood flow and also decreases how insulin is able to do its job, leading to insulin resistance, therefore elevated blood sugar, and that's categorically bad for the brain. If you're a type 2 diabetic, you may have quadrupled your risk for Alzheimer's. So that whole connection is actually really quite fascinating. The discoverer of nitric oxide, this whole chemistry, was awarded the Nobel Prize. For this discovery. I had the opportunity to speak with him actually just last week on this topic. And so we're just learning about that, and it also, as you mentioned, acts as a signaling molecule in the brain. But I love the notion of you want to kill all that bacteria, and that kills 99% of germs— not bacteria, germs. Why? Because germs are the things we have to avoid. We don't want to avoid bacteria, but germs for sure. That's, you know, the germ theory of disease. It's a much more negative connotation. Why do we want to do that? We want a healthy mouth microbiome. And make no mistake about it, we swallow the mouthwash, right? You end up swallowing it after you rinse it out. You still swallow some, and that's going to kill— I don't know if it's certainly not 99% of the bacteria in your gut, but it's certainly going to have an effect on the gut as well. So, you know, point well taken. I recently visited a pharmacy and I took a— made a video of what I saw because behind the counter at the checkout they said, we're here for your health, and they had a whole section behind the counter of smoking cessation products because obviously you don't want to smoke, that's bad for you. And you pan— I pan my camera just a little to the right and there were the cigarettes. Wow. Are they really there to help us with our health? No. Start with the cigarettes, and then when you finally realize it's time to quit, then we still got you. They get you coming and going. So it's we're at the mercy of you know this marketing of like you say the mouthwash and and how they co-opted co-opted the name of Lister, I might add, who you know made these discoveries about carbolic acid and sterilizing your hands prior to surgery, and he had nothing to do with the development of that product, I might add, just out of interest.

Wow. Yeah, I mean, my heart really went out when I saw that, to people who were duped and who were going to be duped by that ad. Also, antiseptic mouthwash ruins many of the cardioprotective benefits of exercise. There was a study that found that— we all know that, I mean, as I mentioned, exercise is one of the most powerful things that you can do to get a healthier blood pressure, which is so important for good brain health. But a study found that people who use antiseptic mouthwash after their workouts— I go to my gym and there's mouthwash literally— Of course. Provided in the gym as a luxury. And I look at it and I always shake my head because I'm— I remember this study that found that people who used antiseptic mouthwash immediately after a workout negated all of the antihypertensive effects of that workout, because oral bacteria also recycle nitric oxide. So they not only help reduce nitrate so that you can basically fuel that pump, prime the pump with nitrate, but oral bacteria also recycle nitric oxide. So after a workout, your nitric oxide is running high. You're boosting nitric oxide with your workouts or by sitting in a sauna. And we know that elevating nitric oxide boosts blood flow to the brain. And in fact, one single nitrate-rich meal Can actually boost cognitive function. That's how powerful it is. But people in the post-workout setting who swish with antiseptic mouthwash thinking that they're— I don't know, that they're doing their health a favor— are actually doing anything but.

Well, I mean, for people who really, you know, have a tough time understanding about nitrates, etc., and this whole nitric oxide discussion, think about what people with angina take when they're suddenly getting chest pain. They pop a sublingual nitroglycerin. And that immediately dilates their coronary arteries and hopefully their chest pain goes away. So that's, you know, a pretty graphic example of how you can dilate arteries. And they generally get a headache too because of the, the sudden increased blood flow over the covering of, over the brain. But it works. Mm-hmm. And you're right, that's what happens after you exercise. But, you know, a meal or any of the lifestyle choices that raise uric acid then compromises it and you're You're offsetting the benefits of your exercise, which, you know, we need. I mean, we need it for so many reasons, not the least of which it changes gene expression to a favorable outcome as it relates to the brain, the BDNF pathway, et cetera. So tangential is great. Any other tangents you want to work— you want to go down?

Well, I just think that optimizing digestion, which begins in the mouth, of course, is very important. And actually, that's a— Something that I talk a lot about in Genius Kitchen, that if you're not digesting your food properly, you're wasting a lot of money, right? Because you're just— you're not reaping the full breadth of benefit that your food could provide you if you're not digesting it properly. And so I think that that's a really important part of the equation, but also acknowledging that digestion begins before you even take your first bite, that we have what's called the cephalic phase of digestion. So just by observing and smelling your food, you're actually— Initiating many of the processes that are crucial with regard to extracting the full nutritional benefit from your food. So sitting down at the table, taking a deep breath, allowing your gaze to soften really helps to stimulate the parasympathetic nervous system.

Oh yeah, it's a sacred moment. I will say emphasizing spending more time chewing your food. Who knew? I've been guilty of not chewing my food enough in the past. And really, I think if you want to be able to liberate all the nutrients that you're talking about, and especially have, you know, accessibility to fiber, and even things like activating sulforaphane by liberating myrosinase enzyme when you're eating your broccoli sprouts, chew your food, spend some time, and don't watch TV. You know, if you're eating, you're eating. If you want to watch the news, fine, but not during the meal. It's a, it's a You know, a sacred moment. It's just as valuable as the time you spend sleeping. It needs to be segregated in terms of this is what we're doing now.

Absolutely. And not only is the news stressful, right, so it actually runs counter to what we know about how to optimize digestion. It stimulates your sympathetic nervous system, right, because the news follows the if it bleeds, it leads mandate when it comes to how they present You know,

I know this is going to be evergreen, but you and I know what's going on in the world right now. We're right, you know, people might watch this in the future, but we're in the midst of this incredible event in Ukraine. And you're right, if it bleeds, it leads, and it's 24/7. So you're right, that's not what you need to be imbibing with food.

With food, no.

You said it so well, we don't need our sympathetic nervous systems activated. That shuts down blood supply to the gut. For the meal, the TV needs to go off. We need to activate the parasympathetic nervous system, good blood supply to the gut, allow peristalsis to happen, and extract from our foods what we need to, that's for sure.

And also, studies show that distracted eating, eating while distracted, whether it's with your smartphone, a magazine, or yes, the TV, leads to an increase by about 15% Of caloric consumption.

That's right.

Well,

Max, it's really good to see you virtually for now, but we somehow managed to get together here and there, so that's good. I look forward to seeing you. And I'm going to, for our viewers, just thank you for putting this book out, again, Genius Kitchen, because, you know, you've made it simple and it's meaningful, and I don't know anyone who's done the work as much as you have in the area.

Congratulations. Thank you, Dr. Perlmutter. Coming from you, that means a lot. So I really appreciate the kind words, and I look forward to sharing a meal with you soon.

I'm there. Thanks. Max's new book is again called The Genius Kitchen, and I am so excited that we had the opportunity to spend some time with Max today. He knows his stuff. He's able to be fluid in terms of being able to change his messaging as new science becomes available, and I really, really value that. in the discussions that I have with people. And that's really very important. It's certainly something that we should all look for in terms of leadership from people who are writing these kinds of books that are giving us such great information. I want to thank you all for joining us today on The Empowering Neurologist. I'm Dr. David Perlmutter, and we will be back soon. Bye for now.