Why Women Should Start Protecting Their Brain Now with Dr. Nicole Beurkens & Emma Heming Willis

When her husband, actor Bruce Willis, was diagnosed with frontotemporal dementia, Emma stepped into an unimaginable role.

We received a diagnosis that I didn't understand. We walked out with no hope, no direction, no roadmap.

Why are we not getting this information out to the public? Why do not neurologists have this conversation with families?

We really need to figure out what is happening, why it's happening. I learned how to separate my husband from his disease. It is not by choice. He is not doing this on purpose.

There's no way of knowing might happen to you and there's nothing that you can do.

It just can happen. And that is hard to grapple with. There are things that we can do today that will help our brain tomorrow.

Well, hello everyone. I'm Dr. David Perlmutter. Welcome again to The Empowering Neurologist. Today's episode is both deeply personal and certainly important from a scientific and an empowerment perspective. My guests are two remarkable voices coming at brain health from very different but certainly very complementary perspectives. Emma Heming Willis is a mother, a stepmother, a wife, and now one of the most powerful advocates for caregivers in the world as it relates to neurodegenerative conditions. When her husband, actor Bruce Willis, was diagnosed with something called frontotemporal dementia, Emma stepped into an unimaginable role that really transformed her into a mission of of support and supporting other people who are navigating the whole spectrum of neurodegenerative disease. She's also the co-founder of Make Time Wellness, a platform that is devoted to advancing women's brain health and closing what she calls this silent gap, really focusing on the fact that women are at higher risk for things like Alzheimer's disease, a topic we've covered quite extensively on the program. And joining her is Dr. Nicole Berkins, who is a licensed psychologist and a board-certified nutrition specialist whose nearly 30 years of work sit at the intersection of brain health, nutrition, and mental wellness. With advanced training in clinical psychology, nutritional biochemistry, and developmental health, she brings a uniquely integrative lens to one of the most pressing questions of our time, which is what can we actually do day to day to protect the brain? Certainly something, you know, we're all interested on— in rather, here on the Empowering Neurologists program. These 2 explore a critical and certainly underrecognized issue. Again, why is it that women are at greater risk for Alzheimer's disease? What a question. We're going to look at things like hormonal transitions, like things that go on during perimenopause, and how they may very well— these issues play a central role. This is a conversation about shifting from fear to empowerment, hence the Empowering Neurologist, giving you tools. So we can be looking at late-stage treatment to even the notion of early prevention. What a notion— prevention of neurodegenerative conditions. And finally, the idea of reclaiming agency over our own brain health. So let's get started in our podcast. I think you're going to find this to be very informational. Emma, Nicole, welcome to the podcast.

Thank you. So great to be here.

Really great to be here. Thank you for having us on.

Oh, my pleasure. Um, you know, I, I, I have to admit that even in getting ready for this podcast today, that, uh, it's not the easiest subject. It's a tough subject. And, you know, no one prepares us for these events in our lives when we are confronted by a neurodegenerative condition or, you know, clearly any challenging medical condition. Uh, but Emma, I get, you know, we'll start with you. Um, Here you are married to Bruce Willis. And what did— let's talk about before any diagnosis was made. What did you begin noticing prior to even seeing a doctor? What was going on?

So what I started noticing with Bruce was that his stutter started coming back. So he had a severe stutter as a child and sort of over the years kind of learned how to, I guess, quote unquote, manage it. What he found was that when he would memorize scripts, that he would be able to recite them without stuttering. And that was kind of what influenced him really to get into acting, besides that he loved it. But he really noticed that that was a really positive thing for him. So, you know, he's always had his stutter. Mm-hmm. But he's learned how to manage it over time. But then I just started noticing that it was coming back and he wasn't really noticing that it was coming back, which I thought was interesting. So that was kind of like the first sign, symptom.

Yeah. And it's interesting because across the spectrum of these types of diseases, you see instances where individuals are had consciously tried to suppress certain things. And then as the disease progresses, they lose that ability to suppress certain things like emotional outbursts, anger, et cetera. You know, people do their best during their lifetimes when their prefrontal areas are working appropriately, they're able to suppress these things. So what you say is really interesting. Ultimately, a diagnosis is given, in his case, frontotemporal dementia. And I, you know, I'm sure the family is shocked and you go home and you look it up. And you realize that, you know, where this is going to lead, what it's going to look like. What happens then?

Well, I think exactly that. I left that office and had to look it up. In that diagnosis appointment, you know, we received a diagnosis that I didn't understand. I couldn't pronounce. We walked out with no hope, no direction, no roadmap, just to check back in in a couple of months. And that was it. So I had to go onto the worldwide web and really take a deep dive into what is frontotemporal dementia. What does this look like for my husband? What does this look like for our 2 young children who were 8 and 10 when Bruce was diagnosed? And what will this look like for our family? So I really realized that just how unsupported we were leaving that doctor's office. So I really had to figure it out on my own.

So you become a caregiver unexpectedly at this time in your life. Now you're a caregiver for your husband. And at some point you went on a mission beyond just caregiving. You know, you're exploring this and wondering why and how does this happen? So So what, when did that shift occur and how did that shift occur from being just caregiving, not just, but, you know, dealing with your husband to realizing there's a bigger calling for you?

You know, I think it took me a minute to even realize that I had become a caregiver. I think there's such a gray area in that to then Understanding that it was really important for me to connect to the idea of being a caregiver. And it was leaving that doctor's appointment with no roadmap and no support. And what I realized is that caregivers are so unsupported and how much that we had to do, how much I had to do behind the scenes to kind of figure out what is the support That we needed. What I think sets us differently than most is the access that we have to really great doctors and experts and specialists, our resources. And I had some time and energy to be able to really figure out what was needed. And When I started surrounding our family with these experts and these specialists, I realized that they were helping me tremendously. And I felt like I needed to pay that forward to the next caregiver who does not have the time, energy, access, possibly resources to be able to figure this out. There's a lot of figuring it out. Yeah. So, This was just, this, yeah, it became my purpose. It became my mission to be able to support caregivers and then to raise awareness around frontotemporal dementia.

So in The Unexpected Journey, you talk about your fear and about how that was sort of a central part of your life, just fear of the unknown. And you did the work to try to begin to understand the brain and what's going on. And as you mentioned earlier, how does the fact that you began to understand what's going on in the brain sort of reduced the fear part of the story?

I think learning about the brain in general, what a healthy brain looks like and what a brain looks like when it is, when it has a disease. I feel like the knowledge helped lower my anxiety, lower my fear. It also learned, I learned how to separate my husband from his disease. Because I think sometimes, especially with frontotemporal dementia, you might think that what they are doing is by choice. It sometimes, it feels like it's a choice that they are making, where in fact, I realized and learned that no, this is because of a disease that is occurring. It is not by choice. He is not— doing this on purpose. So I think learning about the disease was really important. Understanding what a healthy brain looks like versus one that is declining really helped lower my fear and anxiety. I think education is so important when it comes to dementia and how to support someone who was going through it.

But you, you changed ultimately and began to, I think, explore the notion of prevention, right? So how does that happen? How do you go from dealing with the day-to-day situation, empowering others to work through what's going on in their lives, to really, you know, it seems like a paradigm shift that you suddenly ask yourself and then make it a point to make it very public. What's going on? What might we be missing as it relates to this crazy notion of preventing brain degeneration in the first place?

I mean, I think what was so interesting that these sort of two roads were sort of happening simultaneously. You know, I was dealing with my own brain fog and really just not feeling like myself and had gone to my doctor and had, you know, talked to him about these feelings and these symptoms I was experiencing. And in my mind, I was so scared to bring it forward because I'm thinking, Do I have Alzheimer's? Like, what is happening with my brain? And what had happened in that doctor's office was that I was dismissed that, you know, it's just brain fog, it's going to pass. You're not getting enough sleep. You have mommy brain. It'll all come back once you're sleeping better. So, you know, I leave that doctor's office thinking, okay, great, then I'm going to be just fine, but realizing that I wasn't fine. And, I wanted to just dig deeper and I got really curious and started talking to this brain health doctor, Dr. Richard Isaacson, who introduced me to the term brain health, which I had never heard before. I mean, I was looking at him like he was sideways. It took me so long to just process what he was saying that there's meaningful things that we can do today To help our brain that will be super impactful. So I started learning about, you know, these pillars of brain health and through lifestyle change and a fistful of vitamins that I was taking to support my brain, I really started to see a difference. But what I felt just so empowered to know that there are things that we can do today that will help our brain tomorrow.

Yeah, I mean, if there's a light behind me, it would say, who knew? Who knew? I mean, this is people like Dr. Isaacson and I have been doing, and Dr. Dale Bredesen for so long. And it's just the almost silent voices in the woods. But, you know, I think these days there's starting to be some light. So that's a great thing. So how did you two come to meet each other and start working together and ultimately write a book together? Yeah.

Well, I met Dr. Nicole, you know, we had done a podcast together and my co-founder Helen has become, you know, friendly with Dr. Nicole and we just, we love her approach to wellness and her knowledge when it comes to brain health. You know, I am not a doctor. I am a person with an experience. And, you know, we felt, we, you know, thought that it would be great to be able to bring Dr. Nicole into our conversation and to be able to support our mission at Make Time Wellness, which is to get the world talking seriously about women's brain health and to have her come in and really support that mission. We didn't write our book together. I wrote The Unexpected Journey on my own. That is my— that's my book. But, you know, so I'm happy that Dr. Nicole is here to geek out on all the science stuff that I get.

Well, Dr. Nicole, let me ask you, What do you think, you know, one of the outreach issues is the fact that women are underserved.

Yeah.

Let's just call it out like it is. And that's nothing new, to be fair, in terms of medical research, in terms of medical treatment. You know, there's always been a one-size-fits-all based on research done on white males. We'll leave it at that. But that said, what do you think is the main thing missing in the conversation as it relates to women and brain health.

Because women are more at risk. We know that now. And to your point, women haven't been specifically studied in the ways that they should be in every area of medicine, I would argue, but especially when it comes to the neurological pieces, because women are more at risk. 1 in 5 women will be diagnosed with Alzheimer's. 2/3 of the people diagnosed with Alzheimer's are women. So clearly there is something going on there. that makes women in the life transition, in the aging process, more vulnerable. And we have a much better understanding now that it is really the hormone transitions that happen in midlife, in that perimenopause to menopause stage, that are a huge piece of that. And, you know, that life transition has primarily been focused on as, well, that's a reproductive, you know, system issue, and you're going from your reproductive years to no longer being in your reproductive years. That's what that is all about. And we know now that this is really a neuroendocrine system and process that has a dramatic impact, not just on reproductive capabilities, but on so many parts of how our physiology is functioning. And most importantly, I would argue on how our brain is functioning. And so it's really important that this message is coming to the forefront because as Emma stated, Education is empowering, right? I think one of the biggest disservices we do to people in general, whether it's, you know, parents coming in to have their child tested for autism or it's a couple coming in because one of them is having memory issues or brain fog issues. And as practitioners, there's a tendency to, as Emma said, just say, well, we've checked the boxes, we did the test, here's the diagnosis, and go at it.

And we will follow, we will follow the patient basically.

That's right. That's right. That's right. And it does such a disservice because number one, it's not emotionally supportive in any way. And let's face it, any of these kinds of diagnoses are tremendously emotional and impactful, not only for the person receiving the diagnosis, but for their partner, for their family members, for the people that are around them. And we do a real disservice when we just sort of check those clinical boxes and, and move along. And we really owe it to our patients. To be much more supportive, to be including them in the process through education, through talking about what are the things that you can be doing, what are valuable sources of information that you may find helpful right now. To Emma's point, connecting them with resources in their community, helping them understand, for the caretaker even, how they need to be looking out for and taking care of themselves, which is a, you know, part of the conversation that gets left out almost all of the time across the age span, I think. So there's just so much low-hanging fruit there on the clinical side of ways that we can— just simple ways that we can improve this process from diagnosis all the way through treatment. And of course, now for us, our focus is on even the pre-diagnostic component of how we can be educating women and practitioners to be thinking more proactively, to be thinking years and years and years before we start with these kinds of symptoms of how we can be improving our brain health.

Hey everyone, we're going to get right back to the podcast, but I have an important message for you. If you're caring for somebody with Alzheimer's, any other form of dementia, or even what we call mild cognitive impairment, or maybe you've received one of these diagnoses yourself, or if you're focused on preventing cognitive decline, I want to speak directly to you for just a moment about some serious research that's going on. Looking what we call 40 Hz light and sound simulation. We've been actually talking about that on the program. Here's the challenge. Not all 40 Hz light devices are the same. Most use what's called stroboscopic light, and that's the type of light that flashes, then you can see the flashing, and that can cause nausea. It can cause headaches. And if you can't tolerate that, you won't use it. So, there is a company called OptoCeutics. They've solved this problem with a patented technology. That still gives you the 40 hertz light flashing, but through light that looks and feels quite normal. It's the device I actually have on my desk when I'm working. And that's why this company sees a 94% adherence rate and significant improvements across various metrics, including mood, energy, focus, sleep, and memory. And the light is called the Evy light, E-V-Y. You can use it as I do when you're Working on your computer, when you're reading, when you're watching TV, eating breakfast, whatever. It becomes really part of your day, not just another burden. It's kind of passive in the background. So I recommend giving it a try for 90 days. And if you and your family don't see value in it, then you can return the device for a full refund. They cover the shipping both ways. And this is a device that really is risk-free in terms of getting involved with 40 Hz stimulation. Important information. Let's get right back to our podcast. So then what would you tell a 20 or 30-year-old woman she should be thinking about and acting on as it relates to, you know, ultimately setting the stage for brain health in her later years, 60s and 70s? What can we do early on in life for these, for women?

Yeah. You know, this is an important question because in our 20s and 30s, we're, we're, we're getting started with our life. We feel like we have so much time ahead of us. We're in the midst of, you know, finding a partner, having jobs, figuring out, you know, our family, starting a family, those kinds of things. The last thing on our mind is, boy, what should I be thinking about now for what my brain health is going to be like in my 60s, 70s, and beyond? And yet, to your point, it's such a critical piece. Everything that we do. In those earlier decades of our life sets the stage for how well our brain and body will function. We can't stop the progression of aging, particularly when we think about for women going through perimenopause and menopause, that is going to happen. But setting the stage by doing some foundational things in our 20s, 30s, 40s helps create What we might think of as resilience that helps our brain, you know, weather those changes maybe with more ease or with less problems. So, you know, I would say to women in their 20s and 30s, everything you're doing right now to take care of yourself, and if you're not, the things you wanna be thinking about in terms of the food that you're eating, your movement habits, how well you're sleeping, all of those things. are protective and are helpful and are laying a foundation for being able to go through the aging process with fewer problems. So, it's not just what we're doing right now to look good and feel good. It's also realizing it's, it's double duty, right? It's helping us now, but it's also gonna help us in the future. And, you know, we can get into what Emma and I talk about are the pillars, you know, of those things. But I think that that's a really, it, it's a, it's a great way for women to think about it and not be overwhelmed. 'Cause sometimes, like, you say, well, what should I be doing in my 20s and 30s to prepare? It's like, oh my gosh, it's one more thing I have to be thinking about. And the great news is the same things we want you thinking about that keep you looking good, feeling good, functioning well now are the things that are gonna help you later. So it's not a whole extra set of things, it's just prioritizing now the things that you can be doing to lay that foundation for later.

Yeah. And these are the right things for your heart, for your bone density, for cancer risk reduction, and for reducing risk of cognitive decline or full-blown Alzheimer's, because when you are 60 and you're starting to fail cognitively, truthfully, what, what do you have to offer an individual like that?

So I am a big believer that it is almost never too late, but even when someone has been diagnosed, even if somebody comes in, you know, to my office and they're in their 60s and they're already having symptoms, or they maybe have had a diagnosis already, there still are meaningful things that we can do, which I think is a It's a real, it's a new idea for lots of people. And, you know, many patients have been told by their practitioners that it's too late. You know, this is just what has happened now and there's just an inevitable decline and this is what it's going to be. And, you know, what Emma said earlier about the importance of hope, giving people some amount of hope of here are things you can be doing for yourself, for the person who's been diagnosed. And so to me, even in that stage of things, It's not too late to be talking about things like, how are you fueling your body? What are the building blocks through nutrition and diet that you're providing that will support your brain to function as well as it can at this point, you know, given what you have going on? It's things like helping them realize you don't need to undertake this rigorous exercise regimen, especially if you're not in a place where you can do that. But how to incorporate movement throughout the day that will help get the blood flowing, help get the brain, you know, receiving the blood flow and things that it needs to function better. It's focusing on those relationships. You know, even if all else is like, wow, there's really not a lot that can be done here on the physiological side of things. One of the most profoundly important things we can do for patients is help them retain and strengthen relationships and community with the people around them. We know that that is a pillar of brain health throughout the lifespan. And, you know, we hear more talk now about how loneliness has become an epidemic, how loneliness is a driver of inflammation and chronic health issues. So even in the end stage of these diseases, to help families understand that connection, that maintaining those relationships, that engaging the affected individual in life activities to the extent you can, keeping people that they love around them, celebrating things, that has an impact, you know, not only on the physical level, but on the spiritual and emotional level too, which I think is so critical.

Can I add to that? I also think, you know, when we're talking about If you're looking at Alzheimer's and you're thinking about someone who is in sort of that, the later part of that diagnosis, and then, you know, family members or friends are like, well, I'm, you know, I'm not going to go because they're not going to remember me anyway. I think that does a disservice to, you know, the person who is living with the cognitive decline because they might not remember you in 5 minutes, you know, after you have left. But It, they will remember how, how they feel in that, in that moment. And I think that is really important to share that we do not want to discard someone who has Alzheimer's and that their feelings are very important and that you will make them feel that connection by being with them in that moment.

Well, I think both of those statements are really have the same theme, and that is that there is a benefit to Mm-hmm. Throughout the time course of this disease. And, you know, people have kind of brushed that off. Well, we get the idea that exercise enhances the production in the brain of BDNF. That's a trophic hormone, leads to neurogenesis, synaptogenesis, all the things, reduces inflammation, improves insulin functionality, all of that. Sleep does the same thing. But, you know, the idea of connecting to my neighbor or being socially involved, how in the world could— give me the mechanism. And I think we now understand.

Mm-hmm.

That when you are visiting that person, his or her brain increases its production of oxytocin.

Yeah.

When people are socially engaged, they're having higher levels of oxytocin, the love hormone, if you will. The reason I think it's so important is because we now understand that oxytocin binds to the brain's immune cells called microglial cells and helps keep them being supportive and loving versus being destructive. You know, I think these comments about social interaction being kind of second tier. And I think, Nicole, you made it very clear that this is really important, that yes, you need to, you need to visit your, your parent when he or she is end-stage.

Mm-hmm.

It's hard. You know, people say, I don't want to go because it's hard. I know it's hard. You know, here I am, a neurologist dealing with Alzheimer's patients on a daily basis, but visiting my own father day after day, whose nursing home was across the parking lot from my medical practice, Um, you know, and, and at end stage, I, I still think he knew I was there. And I want to keep believing that now that he's gone. So there's value to that. Um, Nicole, I want to get back to, uh, the perimenopause because I think it's really important. We're seeing a lot of science, uh, in this area now, but, um, let's focus if we could for a moment on what you think is actually pathophysiologically Or maybe physiologically, maybe it's appropriate, I don't know, going on in that brain during this hormonal transition that is not favorable.

Yeah.

For close to 40 years, I have found myself in examining rooms watching families struggle through the loss of a loved one, not because that loved one aged, but because that loved one had lost his or her cognitive function. And, you know, Basically, I think we were all told that there was nothing that could be done. And in fact, I even parroted that narrative for quite some time. But ultimately, I found myself in a place of not being able to accept that. I'm Dr. David Perlmutter. I'm a neurologist, and Brain Defenders is my new book, clearly the book that I have spent my entire career building. It's officially launched, and it's available for order right now. And I truly believe that this is the most important work that I've ever done. Inside, what you will find are the hidden threats that are working against your brain right now, and also the exact science-backed actions that you can take to protect your memory, to protect your cognitive function, your clarity, your independence, your ability to interact with other people starting today, not someday, but actually starting today. For those of you who want to be all in, I'm excited to announce that we now have the Brain Defenders Immersion Course, which is a guided path to put the very work that we describe in the book Brain Defenders into action step by step, so that protecting your brain isn't something that you just read about. It's something that you actually participate. It's something that you actually do. Your brain's future is actually being decided right now by the choices that you are making today. So order Brain Defenders and Join the immersion course today, and you can get all this information by visiting my website, which is drperlmutter.com. That's drperlmutter.com to learn more about both the immersion course and the book. I wrote this book for you and for everyone you love. Let's defend your brain together and defend the brains of everyone you love as well. Remember, the time to defend your brain is right now.

So, you know, there's been a lot of, well, I actually shouldn't say there's been a lot of research in recent years. There has been more research in recent years. We still need more and more research. You know, you've featured some of the prominent researchers in this field on your show prior. We need a lot more research labs around the world looking at these things, but what we know at this point is that the significance of those hormonal shifts for women, particularly in perimenopause— perimenopause even more so than menopause. In menopause, things begin to stabilize and even out. It's that chaotic sort of roller coaster of hormones in that, you know, 5 to 10 years leading up to menopause that really becomes very problematic for the brain. That transition from those reproductive years to The state of menopause is, is I think of it both for myself and for patients as a roller coaster. That's how it feels to be going through it. And the brain is essentially having to remodel itself. One of the core things I think to understand, and you talk about this so beautifully, and it's in your upcoming book as well, I know, around brain, the concept of brain energy and how brains require a ton of energy to function well. And glucose is that the primary energy source for the brain. But what happens in perimenopause and into menopause, as those estradiol levels drop— it turns out estrogen, estradiol specifically, is really critical for the brain's ability to use glucose for energy. And so when we start to have those declines, and as those declines become more pronounced as we get closer to menopause, Those estradiol reductions really impact our brain's ability to have the energy that it needs to function well. And so we get all of these symptoms and things, and there's a wide variety, right? I mean, if you ask any woman going through this what her list of symptoms is, you can, you know, amass a huge list of things that there are some similarities and then, you know, some differences across people. But brain things are the things that sort of have been swept under the rug with this, right? Usually when people have talked about Perimenopause or menopause, it's, oh, it's hot flashes and maybe some trouble sleeping, right? I can speak for myself and say, I have never had hot flashes. That has not been an issue for me. But you know what has is the brain-based things. And so many women are reporting this, right? So the brain fog, as Emma mentioned, that sort of like, I call it trying to think through mud. You know, you go from being this high-functioning person, you know, raising kids, having a job, doing all these things, You know, keeping all the balls in the air and suddenly you're like having difficulty thinking about basic things. So the brain fog, of course, the sleep kinds of things, emotional and mood lability, you know, just like, why am I so upset all of a sudden? Or why am I so angry? So we know that physiologically in the brain, what's happening there is the brain is having to remodel. It's having to figure out how to operate and function With reduced levels of estradiol. And that does eventually, for most women, even out as the brain does go through that process and figures out how to support itself and, and create the energy that it needs in the absence of that. But boy, does that take a while, like a decade. Yeah. And so in the midst of that, we are, you know, dealing with all of these symptoms. And again, I think to the point Emma made earlier, just educating women about that alone, Hey, your brain is having to learn and reconfigure itself to operate without the estrogen that it really has depended on throughout your life to be able to produce energy and function well. Just understanding that helps as a woman to go, okay, there's something going on here that I can, you know, name, that I can understand what's happening. It gives us more grace with ourselves too, because, you know, you start having all of these things and you go, am I just going crazy? Like the number of women who have come in, you know, to see me who are like, I, I think I'm developing early Alzheimer's, or I think I'm developing some kind of mental health condition. Like something is really wrong. And then when you look at the physiology and you explain to them, even in very general terms, what's happening, the connection between those hormone shifts and their brain, suddenly there's some relief. It doesn't, it doesn't mean that it makes the the symptoms go away, but it helps bring relief of, okay, I understand at least what's happening for me here.

Well, you know, I think that what you've made clear is that the decline of estradiol may be related. I think when we unpack that a little bit, we see the role of estradiol, as you mentioned, in terms of insulin-related brain metabolism and also in terms of activation of certain pathways that lead to loss of the synapses, the connections between neurons. But so one would think that therefore there's a little bit of justification here then for the idea of hormone replacement therapy. And yet there is such an aggressive pushback in terms of HRT based on an earlier clearly flawed study relating it to breast cancer risk. Mm-hmm. So where do you sense we are right now in terms of doctors wanting to embrace The idea that there may be a role for HRT as it relates to women and their brain preservation.

I think what's important is that we're finally publicly and in our medical conferences and in the general public having this conversation, right? For so long, like for my mom's generation, it just wasn't a conversation that was had. That study came out, the headlines went out there, and it just was not a conversation. So I think it's important that we're having those conversations, that practitioners at major medical conferences are talking about the current state of the research, are talking about the flaws in that study, are talking about what we can do on the hormone replacement therapy side. And I think it's equally important that this message is getting out to the general public so that women have an understanding of their options and can advocate for themselves. Because I think when we go in to meet with our healthcare provider, it's really a collaborative effort. You know, if we're going in as a patient thinking, well, I'm just, you know, whatever, whatever the practitioner says to me, that's it. That's a problem. And it's also a problem if the practitioner's going, well, I'm gonna give the answers and the patient doesn't have any say. I'm a, I'm a huge believer in collaboration between providers and patients. And I think the fact that women are becoming more aware that HRT is, you know, potentially a valid option for them. They're raising this. And I think we are seeing more practitioners. I hope over the next decade, I hope over the next year even, that we have many, many more providers who not only are willing to have that conversation, but have educated themselves more and are initiating those conversations. Because we know that HRT can be a wonderful tool for many women. We also know it's not for everyone.

True. And Dr. Lisa Mosconi has— is currently involved in a study. We hope to see the results soon. And I think she's really going to ruffle feathers in a very, very positive way. Feathers that need ruffling in terms of demonstrating that this is certainly an important tool in the toolkit that we should be considering. So if I could, Emma, let me go back to you. And I think one of the things that But I have noticed a question over so many years from patients' families, and that is why. Why did dad, why did mom get this? Well, you know, and we'll talk about, well then what is my risk later? But you must have labored through that, right? Why did my husband, you know, what went on that set the stage for this? How'd you deal with that question? Because, and were there any answers, anything that clued you in as some— something that may have been causal?

No, I think that is what is so alarming about this. I know that for 30%, it can be genetics. You can see this within the family and you can see it through a grandmother, a brother, and you can see sort of that lineage. And then for You know, 70% of people with FTD, it's sporadic, meaning it just can happen. And that is hard to grapple with because what is it? Why? Um, you know, is it environment? Is it toxin exposure? You know, I've thought about all of it.

Mm-hmm.

But hopefully that we'll, you know, dig into that more. You know, there's this policy that I'm supporting, which is called the Healthy Brains Act. And, you know, they, they want to learn more about why neurodegenerative disease is happening. Alzheimer's, ALS, Parkinson's, FTD. What, what is happening? What are those causes? And they will look at environmental exposures. Yeah. And, you know, we're at a time where, you know, they say like 20, 50 dementia cases are going to triple. So we really need to figure out what is happening, why it's happening, and what we can do to possibly help prevent. I mean, that's a big word.

You know, there's actually a journal for Alzheimer's prevention now. And interestingly, one citation that comes to mind was a— was from last year, a simple study that went on for 12 years, 1,300 adults, I think it was age 65, 70. And what they found was they looked at their consumption of ultra-processed foods. And what they found is for every serving, as an average per day of ultra-processed foods, every handful of chips, whatever, every serving, the risk of developing Alzheimer's was increased by 13%.

Mm-hmm.

And for those people who had 10 or more servings per day, their risk was 3 to 4 times. Increase, 3 to 4-fold increase. So it tells us that, you know, there's a mechanism here we need to understand. It's a change in metabolism and inflammation, number one. And number two, if we know this information, if this, you know, we look at these studies, why are we not getting this information out to the public? But also, why do not neurologists— and maybe this sounds critical, and if it does sound critical, that's good. Have this conversation with families because families want to know. And I, you know, to be clear, when a loved one has this, the, maybe the second or third thing you think of is then maybe I'm at risk. When you see studies like this talking about ultra-processed foods, you begin to appreciate what you both have now really embraced deeply. And that is there are modifiable factors over which we have control that play heavily into our risk for this. Yeah. otherwise incurable situation. When I say incurable, I mean from a standard pharmaceutical approach. And one last thing I'll say, I know this is me interviewing you and I'm going on and on, but subject close to my heart.

Yeah.

The Lancet published in 2024 a study indicating that if we paid attention to 14 modifiable factors, like reducing alcohol, wearing a helmet when we're bike riding, you know, keeping our blood sugar under control, keeping our blood pressure under control, et cetera, 14 modifiable modifiable factors, that rates of Alzheimer's would not increase but would be reduced by as much as 40 to 50%. Yeah. I think that should be shouted from the highest mountain because here we are spending $360 billion right now. That's the number that's always quoted. I want somebody to quote the emotional cost.

That's right.

Because that's, that's the part that That really matters to me most. We're going to get right back to the podcast, but I do have an important message. You know, for decades we've been told that our genes are basically our destiny as it relates to health and that everything's locked in place predicting even our future brain health. But let's be clear, your DNA isn't a verdict, it's a roadmap. And I'm talking to you today about 3X4 genetics. I actually described them in the new book, Brain Defenders. And this is a company that helps you understand your genetics, what you've inherited, and I think more importantly, how your daily choices can influence how those genes are actually expressed. In other words, how you can control your own genetic expression. And you know, that matters for your health and it really matters for brain health, including things like memory and mood and cognitive resilience. You may carry genetic markers associated with cognitive decline, As we've talked about, APOE4, but possession doesn't equal expression. Your lifestyle, your nutrition and metabolic health, all the things that we talk about here on the podcast can powerfully influence which genes are turned on and which stay quiet. The 3x4 Genetics Test looks at how your genes impact brain function at a cellular level, and which then through the 3x4 Health Journey, which they provide you, guide you through a clear and a science-backed program focused on inflammation, methylation, oxidation, oxidative stress, things that we routinely discuss here on the podcast that are the key drivers of basically what makes a good brain go bad. And we have spoken with the team at 3x4 Genetics, and they were able to get a special offer for our podcast community. So head on over to 3x4genetics.com. And get that special offer and start really your personalized brain health journey today. Let's get your genes working for you. And let's get back to the podcast.

We were talking before, one of the questions that you asked Dr. Nicole was like, you know, what are we telling people in their 20s and 30s and how to care for their brain? I still have young children at home. Mabel and Evelyn are 12 and 14, and I am teaching them what a brain-healthy lifestyle looks like. Not in a crazy way. I mean, And the pillars of brain health are, I don't want to say simple, but they, you know, I think how I, what I have learned is that when I care for my brain, the rest of my body benefits. And for them, I'm teaching them that sleep is very important, that connection is really important, nutrition, trying to stay away from that ultra-processed food. They're kids. I'm not going to go nuts about, you know, but I, but I do keep it in check. And, I do think by educating them and how they are seeing how I live my life with exercise and making sure I'm doing strength training and cardio, hopefully they are picking up what I'm putting down. Hopefully, they are learning and seeing, and I know they are, what a brain-healthy lifestyle looks like. And, I think that this is really important to to, to, to talk to kids if you can, you know, bring them into this early so that we're not trying to figure out how to talk to a 20 and 30-year-old who, you know, are trying to do all the things. Their, their brain is moving quickly. So it's, it's been great to be able to get in sort of at, at an earlier stage.

Yeah. You know, all of the pillars that you describe are inroads to metabolism. They're all, they're all reflected in how they affect the body's metabolism, whether it's sleep or diet or exercise. So why do you suppose, and actually I'm going to ask both of you this question, why do you suppose mainstream medicine is turning a blind eye to this as it relates to Alzheimer's?

I think what I'll say is that over the course of my career, virtually every professional colleague in medicine and mental health that I've met has the best intentions. As far as working with and treating their patients. I think we have a huge education and awareness gap by and large, and we see this across the board, not just with neurodegenerative conditions, but, you know, with, with everything that a couple things. First of all, that it takes a really long time on average, 17 years for things to reach clinical practice once they've been shown in research. The other piece is that people tend to learn what they learn when they go through higher education and don't continue— many don't continue to upgrade and update their knowledge on these things as they go, which is why I think that combination of things is why we still have so many practitioners who think that there's nothing that can be done, who tell women and men, you know, well, there's no way of knowing. It might hit you, you know, you might just, this might happen to you and there's nothing that you can do. And once we do diagnose it, there's still really nothing we can do. And I think it really has to do with this education and awareness gap, which is incumbent on all of us as professionals to stay up to date. The number of times I have had conversations with my neurologist colleagues or psychiatry colleagues or even general practitioner colleagues Around, you know, patient care and, hey, we're seeing some of this on neuropsychological testing. Here's what we're observing. Here's what the family's reporting. And they just go, well, we'll wait until this, or, okay, I mean, you tell me what the testing shows and we'll give this diagnosis. There's no sense of urgency around, boy, let's really, let's really start looking at some things now. It's more like, well, it's just inevitable. And when they get to the point of diagnosis, then we'll do that. Which I think, you know, those conversations are an opportunity for me To do some education with people. I think we all, you know, need to be having those conversations. Certainly the work that you have done throughout your career with the books that you continue to write, hosting this podcast, all of the teaching that you do, that's so essential to helping move the field towards a place where this is accepted as foundational understanding of what's going on with the brain and how brain health needs to be a focus. But boy, we are, we're making inroads, but we're just not there. We're just not there yet where it really is the norm.

Yeah. It's also, you know, to educating neurologists or primary doctors about frontotemporal dementia. You know, I think that that is where I'm trying to use my voice to be able to educate doctors about what FTD is and these signs and symptoms that, you know, need to be addressed. You know, FTD is so misunderstood, so underfunded, so misdiagnosed. You know, it can be misdiagnosed as bipolar, midlife crisis, depression, as opposed to there is something significant happening that this, you know, is happening here. And that is a change in the brain and it really needs to be addressed. So I think like, you know, I know it's hard to get into the curriculum, Of how we are teaching our doctors. But it is important. I mean, what I've learned, and I don't know, I've heard that there's 120 different types of dementia. Wow. And not all dementia is Alzheimer's. Of course, it's the most common form of dementia, but there are other forms of dementia. And I think it's really important to continue to talk about so that people understand that Alzheimer's is about memory, but FTD affects people differently. So the education, the awareness is, is so important to be able to move things forward.

I want to say something too about another reason why I think that sometimes providers are hesitant to have this conversation. And it goes to something that you said, Dr. Perlmutter, a few minutes ago about The studies that we see come out now on things like ultra-processed foods, on things like those modifiable risk factors. And I, what I have heard from my colleagues in medicine is that they are hesitant to raise those things because there's a concern it will come across as blaming the patient for what it is that's happening for them. And I wanna acknowledge that because I think it's all in how we approach it, right? I take the flip side approach. approach of what an empowering gift that we can give to patients to help them understand these modifiable risk factors early on and how they can have agency around the day-to-day choices that they're making in their life that help protect and preserve brain function as they age. But I think that's a conversation that needs to be had in In a supportive, empowering way, not a blaming way. And I think that there's just a lot of practitioners and in our, you know, managed care system where people have just a few minutes with patients, they don't have those kinds of conversations. But I think to make that shift from, look, we're not blaming someone for eating potato chips and, you know, drinking soda and whatever and saying, well, now look what's happened to you. To shift that into an empowering mindset of helping them understand the connections between what they're doing day to day, the food that they're putting in their grocery cart, the sleep that they're getting at night, the ways that they're moving their body, the, the activities that they're engaged in, you know, with other people. What an empowering thing to teach people that each and every one of those things. Yeah. helps with brain health, helps preserve your function as you age. It's not a blame lens that we're looking through. It's an empowerment and it's an agency lens.

And I think to look at the time course as well is very important. I mean, I've always used this example because it seems people can, can understand it. And it's having the heart attack. It's as if you're walking down the street minding your own business, you turn the corner, bingo, you have a heart attack out of the blue. It just happened out of the blue. No. As a matter of fact, you know, you have dyslipidemia, you're type 2 diabetic, you don't— the things you don't exercise, et cetera. And this has been building in your coronary arteries for decades. And it's the same thing as it relates to Alzheimer's. You know, it's not a cataclysmic sudden event, but these things happen over time. I have to admit, I was asked recently on a podcast, when do you think people should start paying attention to being on a brain-healthy program? And I said, in utero.

Yeah.

Because think about it. That's right. You're epigenetically modifying the gene expression of your unborn child. So, you know, it really matters. So, you know, it's, this is a very, it's a tough sell. It's a tough message. But, you know, I think it's clear that the 3 of us believe in our hearts that to a significant degree that our lifestyle choices help us chart our brain's destiny. I think that's fair enough. And I can only imagine, Emma, in your In your presentations, it's almost like a plea, I would guess, for people to get this, that it's not pointing fingers that you should have done, you know, Nicole, back to your point, but I think it's for the people who are at least cognitively intact at this point that, you know, okay, I've learned a hard lesson based on mom or dad or my husband or wife. What can I do so I can be around and intact and be supportive of my loved one and my, and my children, et cetera. So I think that's a big part of the message, but it doesn't happen in a 15-minute doctor's appointment.

No, it doesn't. I think that, you know, we, you know, as, as, as a caregiver, I think one, you know, one of the craziest stats that, you know, I had heard caregivers die at a rate that is 63% higher than people their age who are not caregivers. And there is this also this percentage that 30% of caregivers do die before their loved ones. So, you know, going back to the caregiver conversation about how important it is to care for ourselves, for our brains, I think that when you see someone whose brain is declining, for me, it just, it made me want to, I wanted to care for my brain even more. And to know that there are studies out there that do show that we can make an impact on our brain. today. And I do not point the finger at anyone for a diagnosis. When I think about, you know, FTD, I do not point the blame at my husband. There is nothing that he could have done differently to change his outcome. But what we do is that we will continue to support him, and I'm learning how to support my brain and our children's brains. And it's important to share that message. So I appreciate the work that both of you are doing.

So Nicole, what is the one thing you would recommend to a 20-year-old right now that can help self, safeguard her brain?

Get good sleep, prioritize a sufficient amount of sleep every night, 7 to 8 hours on average. It's the best thing that you can do to support your brain now and in the future.

So Emma, what is the one thing you wish everyone knew about the brain?

That there are things that we can do today that will make a meaningful impact tomorrow.

Wow. That's a home run. Emma, what's the one thing you'd like to share with families who are dealing with this type of situation in terms of their loved one?

I think it's important for people to know that they are not alone. I think that it's so easy for families to think that this is only happening to them. That is what I had felt. But I think what I have learned is that there is a whole community out there of people that want to help and support you. And I think that community, when you are walking through a neurodegenerative disease, trying to support your person, trying to support yourself, there is a community out there that will help you and to lift you up. And for caregivers, I think it's really important that they learn how to prioritize themselves so that they can sustain this journey, so that they can take care of of the person that they love and that they are caring for, but you need to be able to care for yourself first.

I wanted to say to both of you, I commend you for your work. I know it's not easy. This is a rough lane to be in, but we need you and you're doing very, very great things for a lot of people. So, you know, I know it's tough for you, Emma, to be going through this. But look what you've done. Look what you've done with this adversity. And again, I commend you both. Thank you for joining me today.

Thank you so much for having us.

Thank you for having us.

Well, that was really, I think, an amazing time that we got to spend together today. What makes this conversation, I think, so powerful is, again, the intersection of different perspectives, the perspective of having to deal with issues like neurodegenerative conditions from a personal perspective, what emotions are involved in that. And then the whole notion of then stepping up and recognizing, you know, there, there are problems here. What can we do to fix them? Emma Heming Willis brings the voice of lived experience, of being a caregiver, of navigating uncertainty, and really of transforming personal challenge Nicole Birkins, Dr. Birkins brings the science, the mechanisms, the data, you know, the hardcore realities of what's going on behind the scenes and turns them into actionable strategies that really allow us to understand how our daily choices shape long-term brain health. And you could see why I resonate with what we, we talked about today. Together, they remind us that of something I think that's really essential, and that's we're not powerless in this story. As Emma highlights, understanding what is happening in the brain can reduce fear and create clarity. And as Dr. Birkins makes clear, the small decisions we make each and every day—what we eat, how we sleep, how much time we get outside, how we interact with other people, how we manage stress—these are not trivial. These are not trivial issues to deal with. They are powerful inroads to brain health. They are the architecture, really, of brain resilience when we make the right choices in these areas. And this is how we shift the narrative away from fear to the place of empowerment. And that shift may be one of the most important interventions that we have. I'm Dr. David Perlmutter. Thank you for joining us here on the Empowering Neurologists Podcast today. I hope you found this information helpful, and we will be back soon. Bye for now.